It’s time to reverse the standardized patient experience

Congratulations, student doctor, you studied hard and scored well on your exams — not only on your MCAT but in your organic chemistry classes as well.  You mastered anatomy as well as pharmacology, neurology and more “ologies” than you care to remember.  Now it is time to get hands-on learning experience, without being able to hide in the library, while preparing for your clerkship shelf exams or showcasing your talents to the orthopedic service while on your anesthesia rotation.

You have made it through four years of college and four years of medical school, only to plummet to the bottom of the food chain in the hospital.  You are now a doctor, in some institutions able to don a long, crisp and clean white coat.  You have access to doctor parking lots and maybe even an exclusive doctor lounge.  You have more responsibilities than ever before, yet your time to complete these tasks is limited.  Congratulations, you are an intern!

Not only are you going to learn about the patient’s history, perform physical examinations and prepare discharge paperwork, but you will learn how each human being expresses pain, sadness and utter distress.  You will see that not everyone speaks your language.  You will experience fights amongst a patient’s family members, divided on how to proceed with their loved one’s care.  Not every patient is going to follow the textbook, nor agree with what you spent countless hours learning about.  No longer will the response to the patient’s ailment be one of five diagnoses labeled A through E that you will bubble in on your multiple choice scantron.  Patients are going to fight back and question you and your judgement.  They are going to demand answers.

As physicians we are given all access passes to people’s lives within seconds.  It is no wonder they hold us to the highest regard; should they not?  After all, patients allow us to remove their clothing, ask personal questions and even look in places generally reserved for their spouses.  Yet, as they maintain a high-level of respect towards us, it is only appropriate to maintain that same level within.  It is crucial to live the role of physician on a daily basis in all clinical and educational arenas.  It is our duty to provide the best care for our patients — but do we?

In a recent study published in the Journal of Hospital Medicine, Dr. Lauren Block and colleagues evaluated internal medicine interns and their interactions with patients.  The article questioned the etiquette of recent medical school graduates, their interaction with patients as well as their overall role and practice among the health care team.  The results of the study demonstrated that only 40% of those studied actually introduced themselves, while a mere 37% actually explained their role.  The article mentions attending physicians lacking the professional etiquette which has become the basis for physician rating systems.  This is a problem.

Can we put some of the blame on the public for not knowing the medical education hierarchy?  Should they know that their lead doctor (attending), may change twice during their hospital stay?  One valid concern that always gets brought up is whether there are too many “cooks in the kitchen.”  I cannot blame people for thinking this way, especially when each team has four members working various blocks of time and shifting in and out of your care cycle.

Doctors must realize their ability to explain clinical information in a means without medical jargon is vital to a patient’s success.  If their recommendations or plan of care is not fully understood by both the patient and other team members, the health care system will suffer.  The patient may suffer further complications requiring longer hospital stays or re-admission, ultimately leading to larger sums of health care dollars being spent that could have been avoided.

I propose we add something to the system.  I ask that we consider an alternative and extra-level of learning, one that is a bit more passive then students are used to.  I propose an additional module where patients (student doctors) are exposed to simulated doctors (actors), as a reversal of the standardized patient experience.  This affords the “patient” an opportunity to experience how ineffective a bad doctor can be.  This allows students to compile a list of mannerisms, key phrases and body language to avoid.  This teaches them lessons which cannot be taught in the classroom or read in a 1250-page paperweight, known as your anatomy textbook.

It is not surprising that medical schools stress empathy onto their students.  There seems to be less and less of it.  Instead of scenarios with one-way mirrors and simulated patients, my proposition is to create a system of simulated doctors.  Let “us” see how things are like on the opposite side.  Show the third year medical school class what it is like when you act unprofessional or when you are not dressed appropriately.  Better yet, let’s see how the student doctor handles being examined by someone whose name they do not know.  This will be a big wake-up call to both medical students and educators.  The reaction will be a lasting one.

The patient experience is another concern.  It is hard to explain a procedure or what a patient may feel, if you have never been a patient. How can you blame someone for being claustrophobic while in an MRI tube when you have never even seen inside one yourself?  How can you expect patients to stay calm while hospitalized when you have never been in that bed?  Now, I am not expecting all students undergo an open appendectomy to know about the postoperative pain, but there is certainly a different vibe amongst my colleagues who have experienced 10/10 pain after sustaining a fractured femur.  There certainly is a greater level of empathy for those “complainers” when you have been in their shoes and experienced their concern, fear, or same painful injury.

There is a great debate: Do you want to see a doctor who attended all of the best training programs, but does not communicate well, or one who is a great doctor, able to communicate his plan and pass along his ideas after earning only passing grades in medical school?  While the medical profession has a duty to preserve academic excellence and a promise for life-long learning, doctors must set internal goals to maintain a professional rapport with those they care for.  Welcome to your intern year, and take a moment to think before you act — what if you were the patient?

Adam Bitterman is a physician. 

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  • guest

    I think the problem goes a little deeper than anything that could be addressed by the ubiquitous “additional training.”

    The bottom line appears to me to be this: doctors these days are treated as though they are workers in an assembly line. When you have hospitalists seeing 30 patients a day, the assembly line model is pretty much the only viable model, especially when you have administrators carrying on about “Lean Six Sigma” principles.

    Of course doctors treat their patients as though they are widgets on an assembly line, because the doctors themselves are being treated as though they are factory workers. It’s deeply unrealistic (and I would argue, also hypocritical) for supervisors to expect assembly-line type efficiency from doctors but then also expect them to observe the etiquette once prevalent in a medical system that doesn’t exist any more.

    • Patient Kit

      You make me wish I didn’t have cancer. :-(

      • doc99
        • Patient Kit

          Thanks. I had already read this. And while I don’t want to minimize all the problems that docs are facing and I certainly don’t want to minimize your suicide rate, I bet we could make a long list together of jobs that are actually worse than being doctors, many of them invisible jobs done by invisible people. True thankless tasks.

          I’ll start the list with the guy who cleans up the room after your neighbor puts a gun in his mouth and pulls the trigger. And the guy who cleans up the track after someone is hit by a train. Twenty years of doing that. That is PTSD.

      • guest

        Aw Kit, I am sorry you have cancer, too. And very happy that you have such a great Gyn-Onc. Just to clarify, I am very happy and not at all jaded with practicing, but that’s because I have a great job with an enlightened MD boss who understands that providing high-quality care requires resources, and makes sure that we have them. Jobs like mine and your Gyn-Onc’s are getting to be fewer and fewer, though, so I think it’s important for those of us who see alarming trends in medicine (doctors and patients alike) to speak up, and identify the things that work and the things that don’t work in our healthcare system.
        What can you do? Write a letter to your hospital administrators complimenting them on the fact that your doctor actually has been given the time to develop a relationship with you, and how that has led to your getting good-quality care.

        • Patient Kit

          Thanks, guest. I’m very glad that you are happy being a doctor and that your employer gives you what you need to be able to practice medicine and be happy. As a harsh critic of our healthcare system myself, I agree with you that it’s important for both docs and patients to speak up about what is wrong with that system. It’s not an easy time to be a patient with a serious illness in this system and I know that it’s not an easy time to be a doc either. I’m going to write that letter you suggested to my wonderful doc’s hospital admins.

          I’m under an extraordinary amount of financial pressure and have gone through this illness under almost constant threat of being cut off from access. Mostly, I just deal with it and find ways to get what I need. But, at times, it gets overwhelming. I think I feel the pressure more whenever I am waiting for results from a new set of tests like I am doing now. Once you get test results once that say cancer, waiting for results of tests is never the same again.

          I really do love talking to everyone here on KMD. We have some amazing and important discussions here, even if sometimes they are truly depressing. I am, at heart, a true optimist though. So, I tend to bounce back from the edge quickly, ready to resume the fight for my life and for a better healthcare system for all of us.

          • guest

            It must be so stressful :-( I think going through any sort of serious or chronic illness is even more traumatic than it used to be, because the healthcare system lets our patients down with such regularity. Fortunately the standard for care where you are is (still) high compared to other parts of the country, and the doctors in NYC are not nearly as affected by the forces that you see a lot of docs writing about here. Hang in there and good luck w/the test results.

          • Patient Kit

            Thank you again. I can usually keep things in perspective and, overall, I know that in many ways I am one very lucky ovarian cancer patient. Things could be so much worse. Every once in a while I have a little meltdown moment, mostly related to the constant fear of being cut off from access to doctors. I do value my doctors very much. I have no complaints about the standard of care I’ve received. It’s been a pleasant surprise, as a new Medicaid patient, what excellent medical care I’ve gotten after hearing so many horror stories.

            I am curious (in general, but specifically about this): Do you really think docs in NYC are less affected by some of the issues we talk about here on KMD? If so, why?

  • doc99

    Remember, they call the one who graduated last in his class in med school “Doctor.”

  • Karen Ronk

    A really great article. Sadly, no quick fix exists for any of the problems you describe. Not to get too doom and gloom, but I sometimes feel we are all regressing as a species in our capacity to empathize with each other. This problem is not exclusive to your profession, but it may be the profession where it has the most negative consequences.

  • eqvet2015

    I think there is someplace that the doctors and patients can empathize with each other without much effort. In order to connect with the patient who has been accused of exaggerating symptoms or having mental, but not physical, problems, the doctor need only attempt to prescribe a non-formulary drug without preauthorization and then argue about what is best for the patient with some humanities major at the insurance company.

    [ducks and runs out of the room]