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Tuesday, March 21st 2006

Standardized Patients

So, in my first year clinical skills course, like so many other medical schools I get to work with standardized patients. First off, I’m scared we may not be getting the cream of the crop. I wouldn’t be surprised if I opened an exam room door to find this guy, as he is.

I’m not sure if it’s my school of just the standardized patient pool in general. Don’t get me wrong, there are some great standardized patients…but there are some wierd ones. And of course, even from my own experience you can take “standardized” straight out of the previous sentence and it holds just as true but this is a rant on trying to turn retirees and the likes into quality actors.

Second, I’m trying to rationalize my experiences with the SPs with what I’ve seen from my work in medicine and my shadowing experiences.

I don’t want to diminish the great opportunities standardized patients bring to us medical students but let me relate this story. I had my first clinical skills test the other day. There were five exam rooms, in our beautiful new clinical skills center, I had to stop at.

There was a “chart” on the outside of each door, and it had the chief complaint and some basic history and then it instructed you to perform some aspect of the physical exam and/or history. For example, “Do A Lung/Chest Exam.”

I get to my first door and am instructed simply to “Take A Sexual History”. I don’t think the patient was quite grasping the point of the exercise, as here is how it went down:

I knock, enter, and introduce myself. As I’m washing my hands I start questioning.

Q. So, Mr. X, what brings you in today?

There is a pause.

A. Uh, I don’t know. Just a check up for my insurance.

I take a seat, and am taken back a bit. Is this a test about getting information form a reluctant patient? I look up at the camera filming me, a little annoyed.

Q. So, nothing seems to be wrong? You don’t have any concerns about your health?
A. No. (Standardized Patient comes out of character) Did you even read the scenario outside? I think you’re suppose to be doing some kind of sexual history or something.

I sit there dumbfounded. I guess I’m going to have to hit the situation right on the head.

Q. Uh, okay. So, Mr. X, how is your sex life?
A. I’m concerned about getting old. Sometimes I can’t get an erection.

Finally, there we go.

It would’ve been more appropriate no doubt for me simply to sit down and say I had been sent in to ask some questions about the man’s sexual history and if he would mind but really, the patient should’ve been able to adapt to the situation.

There’s some loose wiring here between an insurance physical and coming in complaining of ED. It clearly wasn’t intentional, like the standardized patient was instructed to pretend he was coming in for an insurance physical and I’m suppose to find that he’s also concerned but embarrassed about ED.

Of course this is a guy whose write up of the encounter will also play a major role in my grade.

It is difficult to see what these standardized patient exams have to do with medicine. Except I awkwardly bumble through these actors, trying to impress a grade out of them (it was ugly on my part let me tell you), way worse than I do around real patients.

I’m not the med student who was an EMT or a nurse before but still, I’ve worked in ortho-spine office and an optho practice. In fact if we forget about the summer working the funnel cake hut at a Six Flags (and I desperately try to block that from my memory), then medical office work is the only real job I’ve ever had. Granted my experience in the real world is limited to weighing patients, asking what medications they’re on. Even so, something doesn’t feel right about these standardized patients.

I guess close counts more than just in horse shoes and handgrenades and these clinical skill exams being more of a place to practice physical exam skills than actual accurate medical scenarios, that they play their role in my education.

After the test I realized there is something pleasant about being down in the ER. Even beyond the trauma cases, the homeless guy with the abscess or the IV drug user whose needle snapped off in his arm, they know why they came to the ER and the doctors know why they’re there. Okay, not all the time. And most patients don’t come into the doctors office without knowing why they’re there. However, there’s an urgency to the emergency department that makes the relationship between the doctor and patient more on the nose.

The attraction to that may say something about my person-to-person skills.

There’s usually a definitive problem, there may be a lot of detective work to do on its causes, but none of this fumbling around the issue like the other day, with standardized patients whose Oscar dreams exploded on the launch pad.

I guess it is a rite of passage and as much as I criticize it, the ability to practice the doctor-patient relationship and physical exam skills is a valuable one. Indeed I’m sure in my time I will meet innumerable patients more awkward, frustrating or bizarre than any standardized patient I will ever see. How very few are my experiences.