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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