Standardized patients...

[W19]

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To all MS1 & MS2 out there...

How many minutes your school gives you to do an H&P on a patient? I think 15 minutes is too low to do an H&P, take notes etc... They gave us 20 minutes at the beginning to take a history and now they add physical to it and drop the time to 15 minutes... I am getting slaughtered on them... I think it's impossible to do that in 15 minutes...

 

[ChEMD]

Are they expecting a full H&P or a focused one based on their chief complaint?

 

[EMDO2018]

To all MS1 & MS2 out there...

How many minutes your school gives you to do an H&P on a patient? I think 15 minutes is too low to do an H&P, take notes etc... They gave us 20 minutes at the beginning to take a history and now they add physical to it and drop the time to 15 minutes... I am getting slaughtered on them... I think it's impossible to do that in 15 minutes...

No time limit for us, when I volunteer at our free clinic, takes me about 20 minutes.

 

[TraumaLlamaMD]

It becomes possible once you learn to figure out what questions and exams are helpful for the particular patient and which are unlikely to tell you what you want to know. This is the time you should start learning to do that, because in the real world, you can't take an hour to do an H&P.

 

[DermViser]

It becomes possible once you learn to figure out what questions and exams are helpful for the particular patient and which are unlikely to tell you what you want to know. This is the time you should start learning to do that, because in the real world, you can't take an hour to do an H&P.

👍👍👍👍

 

[TheShaker]

It becomes possible once you learn to figure out what questions and exams are helpful for the particular patient and which are unlikely to tell you what you want to know. This is the time you should start learning to do that, because in the real world, you can't take an hour to do an H&P.

Ugh, you obviously don't care about your patients enough.

 

[TraumaLlamaMD]

Ugh, you obviously don't care about your patients enough.

 

[W19]

Are they expecting a full H&P or a focused one based on their chief complaint?

The history is full (introduction, chief complaint, PMH, family history, social history, ROS, summary etc...) but the physical somewhat focuses on chief complaint... However, if someone complains of chest paint, you still have to do a whole cardiovascular assessment... That's how they want us to do it...

 

[W19]

It becomes possible once you learn to figure out what questions and exams are helpful for the particular patient and which are unlikely to tell you what you want to know. This is the time you should start learning to do that, because in the real world, you can't take an hour to do an H&P.

I think 25 minutes would be more fair....

 

[W19]

No time limit for us, when I volunteer at our free clinic, takes me about 20 minutes.

I think I would be somewhat ok with 20 minutes... The way my school does it is weird... You have to say everything you are doing and the professor is watching and listening to you on a monitor; they warn you on an 'interphone' when you have 5 minutes left. I got panicked and lost my train of thoughts...

 

[TraumaLlamaMD]

Still stretching it. You'd basically never leave clinic ever if you took that long on every patient. You'll get much faster at things like the heart and lung exam as you practice them more, even if they take you a while now. You should be starting to form a differential while talking to the patient, and by the time you get to the exam, asking yourself "what information will doing X maneuver give me to narrow down my differential?"

Your classmates are probably also feeling rushed and discombobulated. You'll get there. At some point you'll be able to look back and go "wow, how the heck did I ever spend 10 minutes doing a review of systems?"

 

[DermViser]

I think I would be somewhat ok with 20 minutes... The way my school does it is weird... You have to say everything you are doing and the professor is watching and listening to you on a monitor; they warn you on an 'interphone' when you have 5 minutes left. I got panicked and lost my train of thoughts...

I swear the way some schools due this standardized patient **** is ridiculous. No wonder attendings laugh at what med schools are doing now. There are some attendings that gobble this **** up and love it, but they're usually quite entrenched in the med school academia club.

 

[W19]

I swear the way some schools due this standardized patient **** is ridiculous. No wonder attendings laugh at what med schools are doing now. There are some attendings that gobble this **** up and love it, but they're usually quite entrenched in the med school academia club.

So you think my school is doing it wrong...

 

[pathologyDO]

Sounds like you need to practice more before you go in. Pick a topic from every type of patient and practice with a buddy. Do all the pertinent PEs, and really think about what questions you could ask. Afterwards reflect on what else you could have asked.

Practice makes you more efficient and you can pretty easily fit in an H&P with physical in 15 minutes. They give us 14 minutes, and then 9 minutes to do an entire SOAP note directly after. The 14 minutes even includes an osteopathic evaluation of thoracic spine with a brief treatment. You can do it!

 

[W19]

Still stretching it. You'd basically never leave clinic ever if you took that long on every patient. You'll get much faster at things like the heart and lung exam as you practice them more, even if they take you a while now. You should be starting to form a differential while talking to the patient, and by the time you get to the exam, asking yourself "what information will doing X maneuver give me to narrow down my differential?"

Your classmates are probably also feeling rushed and discombobulated. You'll get there. At some point you'll be able to look back and go "wow, how the heck did I ever spend 10 minutes doing a review of systems?"

If it is that way in the 'real world', I am going to have to learn how to do it...

 

[Jabbed]

I don't think you can do an OSCE level H&P in 15 minutes. These aren't real world expectations.

 

[DrEnderW]

I swear the way some schools due this standardized patient **** is ridiculous. No wonder attendings laugh at what med schools are doing now. There are some attendings that gobble this **** up and love it, but they're usually quite entrenched in the med school academia club.

Couldn't agree more. My school has a similar set up and we have to articulate everything we do, such as:

"My left hand is contacting the posterior 12th rib and pressing in an anterior direction as my opposition hand pushes posteriorly at the level just inferior to the costal cartilage. I am palpating for the right kidney. The kidney could be enlarged due to X, Y, and Z."

Grade is determined essentially by a checklist if you say all the buzzwords. I should be getting a master of fine arts in drama as well.

 

[W19]

Just going to point out the obvious that as an M1 going to your school and telling them that 15 minutes is not enough time to complete an SP encounter is unlikely to generate a positive response.

Unless you are just looking for more stuff to jot down in your notebook...

🙄 By the way, I stopped doing that after seeing that strong reaction against it here... I was wrong about it. Please stop bringing that up again! This is suppose to be a constructive thread. I am just looking for advice on how I can be proficient in doing an H&P in 15 minutes.

 

[DermViser]

Yup. Never mind that the students couldn't actually identify pathology if it was right in front of them...

Don't tell that to the med school administrators - that would then let them know they wasted all that money. Oh wait, that hasn't stopped them before. Let's build a simulator center instead!

 

[tvelocity514]

For standardized patients, we get 10 minutes with a 5 minute review by our faculty member (no physical part). For H&P's it's 20 minutes (it actually depends bc sometimes they give us longer/shorter).

15 minutes is tough but I think it will really help you prepare for the future as an M3+. You never know what kind of attending you will get in the future (strict on time for hx or not), so this will hopefully help you in the long run even though it sucks now. I think if you are struggling with getting it done in 15 minutes, you might have to figure out a way to be more direct with your questions. Try and focus on the problem at hand and know when to interject a word or two to keep the conversation on topic. It could also be how long you take doing the physical part, but that's not something we can really help with since we can't see you do one. If you think this is the problem, practice on your roommate/ s/o if possible to make your movements more efficient. Good luck!

 

[DermViser]

🙄 By the way, I stopped doing that after seeing that strong reaction against it here... I was wrong about it. Please stop bringing that up again! This is suppose to be a constructive thread. I am just looking for advice on how I can be proficient in doing an H&P in 15 minutes.

The problem was you needed a reaction to tell you that keeping a diary of your medical school grievances was weird w/o having figured it out on your own. That being said at least you heeded our advice not to do it.

 

[DermViser]

Their answer, sadly, would probably just be that we need better simulators.

Sadly you're probably right. And if you bring this to their attention, you'll just be on their **** list, so it's not worth it. I can see it working well for certain things --- running a code, for example. It's the other stuff that is the problem - putting in central lines, etc., also u just can't reproduce human pathology signs well in machines. Esp. ones that are of your 70 kg male, when your patients are overweight and obese.

 

[Slack3r]

Just going to point out the obvious that as an M1 going to your school and telling them that 15 minutes is not enough time to complete an SP encounter is unlikely to generate a positive response.

Unless you are just looking for more stuff to jot down in your notebook...

Dammit beat me to it. I came in here solely to ask if this grievance would be noted in his diary...

 

[qw098]

You guys should be happy that it's not like it is at my school... you have a patient.. you talk to him... then you are off to the next room with a "Harvey" (
Harvey® The Cardiopulmonary Patient Simulator) who is mimicking the patient's pathology if there even is one... :-O

I actually need to know **** when interviewing a standardized patient... not just my suave articulation getting me the grades

 

[Slack3r]

You guys should be happy that it's not like it is at my school... you have a patient.. you talk to him... then you are off to the next room with a "Harvey" (
Harvey® The Cardiopulmonary Patient Simulator) who is mimicking the patient's pathology if there even is one... :-O

Tbh, this sounds way better. Not sure why you're complaining...

 

[DermViser]

You guys should be happy that it's not like it is at my school... you have a patient.. you talk to him... then you are off to the next room with a "Harvey" (
Harvey® The Cardiopulmonary Patient Simulator) who is mimicking the patient's pathology if there even is one... :-O

I actually need to know **** when interviewing a standardized patient... not just my suave articulation getting me the grades

I'm pretty sure every med school has the Harvey. Quite different than building a whole simulation center.

 

[Roxas]

Our first standardized patient encounter was just a Hx and obtaining vitals, and we got 20 mins. Our next one we do Hx and an in depth PE (not altering anything due to a suspected differential) and I think we get 45 minutes. Obviously not practical for the real world, but I think they just want us to know all the things we could do as part of a PE.

 

[operaman]

15 minutes may be a little tight for someone just starting out and is certainly not enough time to do a COMPLETE H&P, but do be aware that 15 minutes is exactly what Step 2 CS allots for a FOCUSED H&P. Then you get 10 minutes to write a note. My guess is that your school may be trying to get you accustomed to this timing early on. It also sounds like they want a focused H&P, based on your description. All the things you listed are what I would include in a focused one, and in your example of chest pain you would probably be expected to perform a full heart, lung, and abdominal exam along with checking extremities for pulses, edema, etc. You could probably skip or truncate the neurological exam and HEENT exam, MSE, etc., if they have no complaints related to those systems.

 

[W19]

15 minutes may be a little tight for someone just starting out and is certainly not enough time to do a COMPLETE H&P, but do be aware that 15 minutes is exactly what Step 2 CS allots for a FOCUSED H&P. Then you get 10 minutes to write a note. My guess is that your school may be trying to get you accustomed to this timing early on. It also sounds like they want a focused H&P, based on your description. All the things you listed are what I would include in a focused one, and in your example of chest pain you would probably be expected to perform a full heart, lung, and abdominal exam along with checking extremities for pulses, edema, etc. You could probably skip or truncate the neurological exam and HEENT exam, MSE, etc., if they have no complaints related to those systems.

That is exactly what they want....

 

[TooMuchResearch]

Sadly you're probably right. And if you bring this to their attention, you'll just be on their **** list, so it's not worth it. I can see it working well for certain things --- running a code, for example. It's the other stuff that is the problem - putting in central lines, etc., also u just can't reproduce human pathology signs well in machines. Esp. ones that are of your 70 kg male, when your patients are overweight and obese.

I actually found the central line simulator useful...after I had done a few on people. Useful mostly to practice my set up, i.e. kit prep and ergonomics. It was not super helpful before I had done them on people.

 

[DermViser]

I actually found the central line simulator useful...after I had done a few on people. Useful mostly to practice my set up, i.e. kit prep and ergonomics. It was not super helpful before I had done them on people.

Isn't the whole point of the central line simulator to practice the actual placement of a central line?

 

[DermViser]

I think the most helpful part of the central line simulators is to get used to the setup, laying out all the equipment you need, and getting used to doing the procedure in a systematic, step wise fashion.

Unfortunately, until you've done it at least once or twice in real life, the importance of this practice opportunity is lost on you. So the sim lab practice is wasted until you have a context to put it into.

I think so as well. Once you've done one at the bedside, with your upper level guiding you, then going back to the sim lab to do it would be much more helpful so you're almost replaying in your head what you did at the bedside in your head when you're doing it again in the sim lab. Of course some parts of it can't be reproduced.

 

[Psai]

I wish that we could have actual bedside teaching where people take you to the bedside, watch you do an h&p, verify your findings and show you how to do physical exam techniques properly and give you constructive feedback on your performance and your note. Is that really too much to ask? Do I really need to do a h&p on some standardized patient's fake problem with zero feedback besides a numerical grade that doesn't help me at all? A lot of the time I feel so lost in third year, I'm just doing things by myself and have no idea if I'm doing it right

 

[Apoplexy__]

a lot of the time I feel so lost in third year, I'm just doing things by myself and have no idea if I'm doing it right

I went 2 months in IM with the same preceptor without knowing if I was doing certain things right. I literally tried multiple times to ask, but she either slipped away before I could or wouldn't give me a real answer.

Then, around week 6 they find out you're doing that stuff wrong and they're like "it's week __, how do you not know this by now?"

 

[Psai]

I went 2 months in IM with the same preceptor without knowing if I was doing certain things right. I literally tried multiple times to ask, but she either slipped away before I could or wouldn't give me a real answer.

Then, around week 6 they find out you're doing that stuff wrong and they're like "it's week __, how do you not know this by now?"

this has happened to me before
i'm like it's week ___, why have none of you corrected me yet
it's hard to explain the huge tuition, i feel like i've taught myself 50% of the things i know from outside resources

 

[DermViser]

I wish that we could have actual bedside teaching where people take you to the bedside, watch you do an h&p, verify your findings and show you how to do physical exam techniques properly and give you constructive feedback on your performance and your note. Is that really too much to ask? Do I really need to do a h&p on some standardized patient's fake problem with zero feedback besides a numerical grade that doesn't help me at all? A lot of the time I feel so lost in third year, I'm just doing things by myself and have no idea if I'm doing it right

What do you think this is? Med school? In all seriousness, the standardized patient encounters are supposed to come with feedback. Part of the problem is that the experience is so contrived and fake that you just go thru the motions only to check boxes off a rubric. Do you guys do OSCEs?

 

[DermViser]

I went 2 months in IM with the same preceptor without knowing if I was doing certain things right. I literally tried multiple times to ask, but she either slipped away before I could or wouldn't give me a real answer.

Then, around week 6 they find out you're doing that stuff wrong and they're like "it's week __, how do you not know this by now?"

Reminds me of this:

 

[TraumaLlamaMD]

What do you think this is? Med school? In all seriousness, the standardized patient encounters are supposed to come with feedback. Part of the problem is that the experience is so contrived and fake that you just go thru the motions only to check boxes off a rubric. Do you guys do OSCEs?

Most of our SP and even OSCE feedback was on the touchy-feely patient rapport stuff, like "you made me feel very comfortable when you explained what you were going to do each step of the way" or "I felt like you were judging me when you asked why I like to drink three pints of vodka a day." There was little to no feedback on the actual exam, in terms of whether we were doing it correctly or even examining the right things. Asking the SPs for this feedback would simply earn an "I don't know, I'm not trained in that," which is fair enough, I guess. But it would have been nice to have feedback on it from a real physician.

However, part of our clerkship evaluations are supposed to include an H&P observed by the attending, and while this doesn't always happen, I got my most valuable feedback from these sessions. We also had a fair bit of bedside exam teaching on certain rotations.

 

[D2thaJay]

We just had our final for our first year clinical skills and they gave us 30 mins. The was for a full subjective with a complete review of systems and partial objective portion. For objective portion we had to take vitals and do a physical exam for skin/nails, HEENT, Heart, Lungs, abdomen. Then we had 30 minutes to type up those coresponding portions of the SOAP note.

 

[DermViser]

Most of our SP and even OSCE feedback was on the touchy-feely patient rapport stuff, like "you made me feel very comfortable when you explained what you were going to do each step of the way" or "I felt like you were judging me when you asked why I like to drink three pints of vodka a day." There was little to no feedback on the actual exam, in terms of whether we were doing it correctly or even examining the right things. Asking the SPs for this feedback would simply earn an "I don't know, I'm not trained in that," which is fair enough, I guess. But it would have been nice to have feedback on it from a real physician.

However, part of our clerkship evaluations are supposed to include an H&P observed by the attending, and while this doesn't always happen, I got my most valuable feedback from these sessions. We also had a fair bit of bedside exam teaching on certain rotations.

I'm surprised your OSCE feedback on a clerkship was the touchy feely stuff feedback vs. the standardized patient encounters which always have that stuff. Part of the problem (which you'll realize later) is that academic attending faculty have so much on their plate and it just continues to increase while reimbursements increase (thus necessitating they see more patients), that student teaching and feedback is low on their plate of all the things they have to do. It really is frustrating for all involved - as students want feedback to improve but aren't getting it, interns/residents are way too busy, and your attending doesn't really do much as far as seeing exactly how you are doing in terms of physical exam maneuvers.

 

[Ismet]

To all MS1 & MS2 out there...

How many minutes your school gives you to do an H&P on a patient? I think 15 minutes is too low to do an H&P, take notes etc... They gave us 20 minutes at the beginning to take a history and now they add physical to it and drop the time to 15 minutes... I am getting slaughtered on them... I think it's impossible to do that in 15 minutes...

Are you an MS1? Interesting that they already have you down to 15 minutes so early in the year, but I think the earlier you start learning how to be efficient, the better. It just takes practice. Practice with a buddy, that's what a lot of us did before these kinds of exams.

Soon you'll be able to get the pertinent history and physical findings in 5 minutes. In the ED we're given the 5 second/5 minute rule - 5 seconds to assess whether sick/needing emergent medical attention vs not sick, 5 minutes to get the pertinent H&P. 15 minutes is an eternity and no one has time for that except for MS1/MS2, especially not in the ED or outpatient setting when you can usually see multiple patients in 15 minutes.

 

[DermViser]

We just had our final for our first year clinical skills and they gave us 30 mins. The was for a full subjective with a complete review of systems and partial objective portion. For objective portion we had to take vitals and do a physical exam for skin/nails, HEENT, Heart, Lungs, abdomen. Then we had 30 minutes to type up those coresponding portions of the SOAP note.

So in others words you went thru the motions.

 

[DermViser]

Are you an MS1? Interesting that they already have you down to 15 minutes so early in the year, but I think the earlier you start learning how to be efficient, the better. It just takes practice. Practice with a buddy, that's what a lot of us did before these kinds of exams.

Soon you'll be able to get the pertinent history and physical findings in 5 minutes. In the ED we're given the 5 second/5 minute rule - 5 seconds to assess whether sick/needing emergent medical attention vs not sick, 5 minutes to get the pertinent H&P. 15 minutes is an eternity and no one has time for that except for MS1/MS2, especially not in the ED or outpatient setting when you can usually see multiple patients in 15 minutes.

The worst is asking ROS like it's a checking off of boxes. It's easier later when you're correlating the ROS with diseases you've learned so you don't feel like you're reading the sheet.

 

[alpinism]

I wish that we could have actual bedside teaching where people take you to the bedside, watch you do an h&p, verify your findings and show you how to do physical exam techniques properly and give you constructive feedback on your performance and your note. Is that really too much to ask? Do I really need to do a h&p on some standardized patient's fake problem with zero feedback besides a numerical grade that doesn't help me at all? A lot of the time I feel so lost in third year, I'm just doing things by myself and have no idea if I'm doing it right

That's because a large portion of the PE is worthless. They'll still get the same labs and imaging anyway.

As one of our attendings likes so say: "I listen to their heat and lungs because the patients expect it, not because it gives me any helpful information."

For some patients a focused PE can be very helpful, however.

 

[touchpause13]

Our first standardized patient encounter was just a Hx and obtaining vitals, and we got 20 mins. Our next one we do Hx and an in depth PE (not altering anything due to a suspected differential) and I think we get 45 minutes. Obviously not practical for the real world, but I think they just want us to know all the things we could do as part of a PE.

2nd year they are 20 minutes

 

[Flamen04]

Our school only gives us 10 minutes for H&P... You kids complaining about getting 15 minutes are spoiled.. (Pro Tip: Step 2 CS stations are also 15 minutes long)

 

[TheShaker]

Sometimes I wonder if practicing physicians do half the things we do. Like, in the CMH we have to ask things like if they have functioning smoke alarms in their home and if they wear a helmet when riding a bike. In the physical, we have to do things like percussing for the upper/lower borders of the liver. I've never had the doctor do this to me... Is this just the kind of thing you do when it's relevant? We have to do it all when we're being graded, but I don't see myself ever spontaneously asking a patient if their smoke alarms are activated.

 

[Ismet]

Sometimes I wonder if practicing physicians do half the things we do. Like, in the CMH we have to ask things like if they have functioning smoke alarms in their home and if they wear a helmet when riding a bike. In the physical, we have to do things like percussing for the upper/lower borders of the liver. I've never had the doctor do this to me... Is this just the kind of thing you do when it's relevant? We have to do it all when we're being graded, but I don't see myself ever spontaneously asking a patient if their smoke alarms are activated.

If you've never had a doctor feel for your liver borders, then they have never been suspicious of a problem in which your liver might be enlarged.

1st and 2nd years learn and practice all of the main parts of a physical exam so that you know them for when you have to do them. You don't do all the motions in real life because 1) there's no time and 2) it's not necessary. If someone comes in with 5 days of runny nose and cough, why would you need to check their liver span or do a cranial nerve exam? It wouldn't change your management. Now if a person comes in with CHF, that's when you whip out your liver percussion or scratch test skills.

It also depends what field you're in and the doctor's personal preference. Primary care pediatrics? You're absolutely going to be asking about smoke detectors and other home safety questions at their regular checkup. Less relevant for inpatient medicine and adults, though some docs still do. I've worked with docs who do domestic violence screening on every female patient they see. Most only do so if there's a high index of suspicion.

You start to develop all this in 3rd year or as you get close to 3rd year. Also a regular physical exam (like for a yearly checkup) is not the same or as detailed as the full physical you learn in 1st/2nd year. You'll pick that up rather quickly when you have your first outpatient rotation.

 

[pathologyDO]

That's because a large portion of the PE is worthless. They'll still get the same labs and imaging anyway.

As one of our attendings likes so say: "I listen to their heat and lungs because the patients expect it, not because it gives me any helpful information."

For some patients a focused PE can be very helpful, however.

Let me start by saying I agree that a focused PE can be very helpful, I agree with that....

But am I the only one that thinks this doctors quote is terrible? He says that heart auscultation doesn't give you any helpful information? Where my cards people at.

 

[Ismet]

Let me start by saying I agree that a focused PE can be very helpful, I agree with that....

But am I the only one that thinks this doctors quote is terrible? He says that heart auscultation doesn't give you any helpful information? Where my cards people at.

Of course it helps for the patients with relevant complaints. But if your patient has knee pain, what's on your differential that makes you listen to their heart? Most primary care docs I've worked with listen to the heart and lungs regardless of what the patient is complaining about, but why?