The impact of assumptions on patient communication in medical training

At one of the medical schools where I am a standardized patient (SP), a student recently failed a portion of the exam because he did not ask his SP questions that were integral to her medical care. When asked by his faculty preceptors why he didn’t ask the SP key questions about her background (she was a Hasidic Jew who couldn’t take her medication on the Sabbath), the student, who was also Jewish, replied, “I didn’t have to ask, I just knew.” He may have inherently understood her culture, but instead of talking to her about it and using it to build commonalities and trust, his decision to not address her background left her feeling disregarded and misunderstood.

Several years ago, I was an SP for a different case that involved an abused woman who presents to her doctor with non-specific, diffuse stomach pain. Although her pain is real, since she was punched in the abdomen, she is hesitant to reveal this out of fear of retaliation from her boyfriend. The SP provides only vague answers until the students are able to gather enough information to realize that this stomach pain is a secondary issue, and the primary concern is domestic violence. For this role, I was wearing a medical gown and given moulage on my arm and abdomen to simulate bruises. The students were to interview me and, at the very least, perform an abdominal exam. This would ensure that the student would see bruising during the physical, thereby allowing further questioning, especially if they didn’t elicit any information about abuse during the interview. For my role, I would then admit that the bruising was caused by my boyfriend. The students should then provide resources and basic counseling about domestic violence.

I have participated in this case many times over the years, and although there have been varying degrees of proficiency among trainees, every previous student had identified the abusive element of the case and provided appropriate counseling. All the students, that is, except one.

During the interview portion, this student missed all of the clues I provided about the abuse. This was not entirely uncommon, although this particular student also hadn’t shown any sign that he was listening to my answers. He wasn’t taking notes, asked no follow-up questions, and his body language indicated that he was not engaged in the interview. Still, I was hopeful that when it came time to do the physical exam, he would notice the bruises and ask about them. But instead of laying me supine on the exam table and exposing my abdomen like he had been taught to do (and like all his colleagues had done), he had me remain seated and only briefly pressed his hand on my stomach over the gown. And that was it for his physical exam. No exposure or inspection of the abdomen, no palpating, no auscultating, no laying me supine. Nothing. He then informed me that my pain was all in my head, that I was making it up, and I needed to see a psychiatrist to deal with my mental issues. Not only did this student fail to discover the abuse, but he also insulted and disrespected me by invalidating my concerns. His counseling portion consisted of him referring me to a therapist to help me with my hypochondria.

Later, his preceptors told me that this student said he was so sure from the beginning that he knew what was wrong with me (i.e. hypochondria) that he tuned me out and went through the motions of asking the requisite questions, never considering my answers or questioning his initial diagnosis. “I just knew …” was his answer when in reality, he knew nothing.

This student’s assumptions and arrogance flabbergasted me enough that I spent time considering what I would have done were this an actual physician encounter. What would happen if I were in an abusive relationship and I came to him for help? Had he insulted and belittled me in the manner he did, I would never have returned to him, and I might not have turned to any other health professional either. I was not only denied help, but I was also made to feel that I was crazy and a waste of time. His refusal to listen to me because he “just knew” what was wrong with me could have resulted in me returning to my abusive boyfriend where my health, and even my life, could be in jeopardy.

As an SP, I wonder whether trainees with negative behaviors during SP encounters will correct these behaviors prior to becoming fully trained physicians. Can such behaviors be corrected by classroom learning? Do many years of internship, residency, and fellowship eliminate such behavior? I worry at times that the answer is no. If the negative behaviors I encounter as an SP are the byproduct of personal ego, could these behaviors or attitudes potentially become worse when trainees are granted career independence as practicing physicians?

In actual practice, patients may not be forthcoming with important information due to many fears and concerns, perceived or real. For them, a doctor who doesn’t listen and makes assumptions about the situation without directly communicating and questioning the patient may be dangerous. In many cases, patients need to first establish a relationship of trust with their doctor before discussing personal, scary, or potentially embarrassing details that may be pertinent to their health. For these patients, a doctor that simply asks sincere questions and genuinely listens to what the patient has to say can make all the difference. My advice to medical providers at every level of training or practice is that you should have a healthy skepticism of your assumptions. You always have to ask, and you always have to keep communication open with your patients. Even if you are certain that you “just know,” please take the extra time to confirm that your assumption is true. You may be surprised to learn that you didn’t know what you “just knew.”

Esther Covington is a professional standardized patient.

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