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To Plan or Not to Plan

I vividly remember my first standardized patient encounter during my third week of medical school. Students would see patients in pairs to gather feedback from our standardized patient and our peers. Leading up to Wednesday, I read and reread Bates' Guide; practiced taking medical history with my classmates; and spent more time in the evenings trying to perfect what to ask. I wanted (and needed) to plan everything out ahead of time. I did not know what the case would be, but I wanted to be more than well prepared.

The script kept replaying in my head: “Hello, Mr./Ms. Smith. My name is Emily, and I am a medical student on your care team. Could I please confirm your date of birth? What brings you to clinic today? What were you doing prior to this? How long has this been happening? Does it hurt? Can you describe the pain—dull, sharp, pins and needles? Does it radiate anywhere? Do you feel any other unusual sensations or notice any other related symptoms? What have you been doing to relieve the symptom, or what exacerbates it? What other concerns do you have related to this or to your general health?” I practiced this script in the gym, in the kitchen, in the shower, and even in bed before falling asleep. These short questions are made to be easy for patients to understand, and I was confident that my standardized patient would be able to answer them.

I was so anxious the day of my first encounter that I could not even stomach a small lunch. But I was ready—or at least I kept telling myself that.

Upon entering the room, my partner and I quickly jotted down notes from the patient information sheet. The patient experienced racing heartbeats. I thought about questions to ask for this specific case. How often do these racing episodes occur? What seems to be the trigger? Any shortness of breath, syncope, weaknesses in any part of the body? And any caffeine or alcohol intake?

“Hello, Mr. Smith. My name is Emily, and I'm a medical student who will be taking care of you.” Introduction … check. “What brings you in today?” My rapid-firing of questions was met simply with instantaneous answers. Well, at least I got out all the questions I wanted and finished within the allotted time.

During the 5-minute feedback session, the standardized patient asked a few questions that stuck with me. What did you notice about my responses? They were short and concise. How would you describe the patient's state today? Patient seemed nervous and was very worried about his heart condition. Did you try to address my concerns or try to establish rapport with the patient? No … I was focused on asking the questions I prepared while not stuttering, writing down the answers, and making sure I finished within the allotted time. I noticed that you asked a lot of “did,” “do,” and “what-type” questions. Try to answer these questions for me. Did you bring a pen today? Yes. Did you bring your stethoscope today? Yes. What is the color of my shirt? Blue. What did you notice about your answers? They were all one word. With one-word answers, do you think it would be easy to establish rapport with your patients? No. Would it be possible for the patient to explain their situation or tell their story? Probably not.

The standardized patient encouraged me not to rely solely on a checklist during patient encounters. Although organization is important, I should try to engage the patient in conversation. I needed to let the patient guide the encounter before I asked supplemental questions. More often than not, the patient's story will reveal something to inform the diagnosis and treatment plan. My standardized patient challenged me to rephrase the way I asked questions; use fewer “did,” “do,” and “what-type” questions; and not come off so methodical.

Every patient encounter will be different. As medical students, we need to build the skillset to manage unexpected situations instead of relying on a script. It is okay if everything does not go according to plan as long as we remember that the patient in front of us is most important!

As a premed student, I was accustomed to going off a “checklist for a successful medical school applicant.” My life revolved around organizing and planning (often months and even years in advance). I like to know what I am getting myself into and what to expect. In this case, I was so focused on asking every single question I had prepared in order to write a detailed encounter note that I didn't try to address the concerns of the patient in front of me.

Through my first year of medical school, I have been learning to extrapolate the information needed for each patient encounter by simply taking the time to listen to my patients' stories. My advice to other medical students is that there is no perfect formula and that medical situations are not always going to go by the script, even with patient actors. Relax and let your creativity and experiences guide you, because they are what truly define you. In the end, you may be surprised with unexpected results and eventual success. We cannot expect our patients to present their symptoms exactly like the case we went over in class or like a previous patient with the same symptoms. Each patient is a unique human being, not just a disease or a group of symptoms. Remember why you came to medical school—because you are an inquisitive and empathetic individual. You came to learn how to serve your patients, build relationships with them, and empower them to take control of their health. You came to make a positive impact on other people's lives.

As the Joker in The Dark Knight once said, “Do I really look like a guy with a plan?” Sometimes the answer is no, and that is okay.

Emily Lee
Virginia Commonwealth University
School of Medicine
Class of 2021

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Back to the December 2019 issue of ACP IMpact