Have you ever been asked to “please dislocate your left breast,” or if you “have noticed any hairs growing in places you normally wouldn’t have hairs”? Or maybe someone told you to “have a nice day” after your spouse just passed away or you’d received a cancer diagnosis. Not only do I hear things like this from time to time at my job, but I have grown to expect them.
I have been working for several months as a so-called standardized patient. The local medical school runs an excellent program that lets students conduct histories and physical exams in a simulated, standardized setting. This means I (and many others) pad around in rubberized socks and breezy hospital gowns and feign myriad diseases, syndromes, conditions, and (sometimes nasty) habits. It also means I overuse hand sanitizer and have many strangers listen to my heart, palpate my abdomen, and poke me with a broken wooden Q-tip to test my sensation. One time I even let someone stick their gloved hand in my mouth and squeeze my tongue a little.
As a standardized patient, I have to memorize case materials for fictional patients. This means memorizing not just a list of symptoms and how long the “patient” has had them, but also the patient’s occupation, education, diet, marital status, drinking habits, exercise, stress, family history, and past medical history. If I am supposed to experience or not experience pain when they poke me, or have a knee jerk reaction (literally), I’d better be ready with a realistic response. This involves a bit of groaning, some crying (in the case of bad news), and some bona fide reflexes.
Most often the students show concern and empathy. In the rare case, though, that they say something a patient could perceive as judgmental, we “patients” get to act grumpy and less compliant.
I am expected to give specific, memorized lines about my symptoms, but only if the students ask the right questions in the right way. For example, if a student asks if I use tobacco, that is different from asking if I use or have ever used tobacco products. Asking a woman if she has ever been pregnant is different from asking if she has any children. And, of course, those types of oversights in questioning can lead to different diagnoses.
Luckily, I am not just a living cadaver for the medical students to practice on. I also give feedback. We evaluate the students on things such as how they organize their questions; whether they display empathy; how they perform the physical exam; and how they communicate the possible diagnoses to the patient. After the exam we have time for students to ask questions and for the standardized patients to give suggestions—like how to encourage patients to change their habits, or what would be better wording to deliver bad news.
From this experience, I have learned what to expect from an ideal physician, what to ask, and what not to tolerate. For example, your doctor should not ask leading (or possibly judgmental) questions such as, “You don’t smoke, right?” Nor should they run off a list of questions such as, “Do you smoke, drink, or use drugs?” without giving you time to think. They should ask open-ended questions: “Have you noticed any other changes lately?”
I’ve also learned that it’s important to pay attention to symptoms that may seem unrelated to your chief complaint. If you were experiencing extreme fatigue, for example, you might not think that your newly brittle hair had anything to do with your energy levels, but it could be a thyroid problem.
Even though I am trained to train medical students, this only means I know what (or how) they are supposed to ask or not ask. It did not necessarily mean I knew what to ask when I saw my own doctor.
Recently, I went to my own physician for knee pain. The doctor instructed a medical student to ask about my symptoms while she (the doctor) went out of the room, presumably to doctor someone. The medical student reviewed my complaints. What made the pain better? Worse? Did the knee make any sounds? The student said that it sounded like a very common problem; she just couldn’t remember the name exactly. (Whether she really couldn’t remember or was refraining from diagnosing me without a medical license, I will never know.)
The student left to get the doctor, and when they returned the doctor moved my knee cap around a bit and then suggested that I might have premature arthritis (I’m close to thirty) and that I may need cortisone shots and physical therapy. I refused to believe this, but said “Oh, okay,” nodding complacently. The student and the doctor left the room to give me time to get my pants on, and when they returned, the doctor admitted that the medical student had come up with another possibility: runner’s knee. I read the photocopied pamphlet they handed me, and it fit all of my activities and symptoms.
I was grateful that my physician was willing to listen to the medical student, though a bit terrified to think what I would have put myself through if she hadn’t. Though I know better now from my work as a standardized patient what the doctor could and should ask me, I am still at their mercy if they do not ask the right questions and listen carefully to the answers.
How to Make Your Doctor’s Appointment Better Than Standard: Advice from a Standardized Patient
• Find a physician who will ask you many questions and listen carefully to the answers. Do not assume, if you’ve talked to a medical student or other proxy, that they have conveyed all the information to the physician.
• Your physician should give you more than one possible diagnosis. In other words, they should tell you what they are thinking, unless they are absolutely certain what is wrong. This should be like a conversation between you and your physician. Don’t be afraid to ask, “Are there any other possibilities for what this could be?”
• Pay attention to your own body. Notice when the pain started and what makes it better or worse. Does it happen at a certain time of day or after certain activities? Have you changed your diet recently? Tell your physician about everything you’ve noticed that is not normal for you, even if you don’t think those other symptoms or changes are relevant.
• As I learned with my knee problem, some medical students—because they are not overly confident and are willing to ask, not assume—are better than some doctors.
Image: Craig Breil/University of Michigan MSIS (not a picture of Amy)