Emily Yoffe was online at Washingtonpost.com on Thursday, July 5, to discuss her adventures as Slate's Human Guinea Pig, the latest of which involved being examined by medical students. An unedited transcript of the chat follows.
Emily Yoffe: Hi, I'm Emily Yoffe, Slate's Human Guinea Pig. Today I'm going to be talking about my experiences as a "standardized patient," in which I volunteered to be examined by 23 Georgetown University Medical Students and lived to tell about it.
Seattle, Wash.: How did you find this job? It sounds like the perfect day job for me, but I e-mailed the local medical school (University of Washington) and they didn't seem to know what I was talking about. I even mentioned being an actor, and they didn't seem to think that qualified as "relevant experience". Is there some kind of central patient casting agency?
Emily Yoffe: Try this site: www.aspeducators.org, the association for standardized patient educators. They may be able to direct you to who at your local medical school handles standardized patients. Being an actor is very relevant. They look for actors!
Fayetteville, Ark.: As one of those "fifty-ish" physicians you mention in your charming piece, we did not learn on sample patients when I was in med school. Although it would no longer be considered acceptable and likely bred some bad habits, at my top-tier U.S. medical school we learned on living, occasionally breathing real patients. The motto was "watch one, botch one." With minimal supervision and no hidden cameras, we simply went to the ER at the adjoining public hospital and helped the residents clear out the chart rack of sick and injured patients that were crowding the emergency department. The budding surgeons helped put in IVs in the "knife ad gun club victims" seen in the trauma rooms and nascent gynecologists learned to identify the "PID shuffle" in the poor souls who had waited to treat their STDs until they could barely stand.
It was hardly a way to deliver quality health care or impart good clinical teaching and I trust that these experiences have largely gone the way of electro-convulsive therapy, but we came out of med school knowing which end of the otoscope was up.
Emily Yoffe: Thanks so much. For people who might stumble into emergency rooms today, I'm glad the system has changed. But medical students stumbling around inside innocent patients does make for good stories. I'm glad you think this new system is better. Some doctors think the way they learned was the best way.
Nashville, Tenn.: What was the funniest question a med student asked? Did you ever have to "break" character? Any residual pain from the experience?
Emily Yoffe: One of my favorite comments from the students was when one was testing the muscle strength of my legs and arms and after I pushed back really hard he said impressed, "Did you do sports when you were young—I mean NOW!" That made me feel old.
When the student took my bra off I did contemplate ending the exam, but I didn't want to get him in that much trouble, and I thought, "I've got to see how this plays out."
Harrisburg, Pa.: Did any of the 23 doctors observe anything that none of the others did not, and did this seem to be a worthwhile observation?
Emily Yoffe: One said I had "good mucosa"—which is something we all want to hear. I asked the doctor in charge what was the protocol if one of the students found something alarming and she said they weren't there to diagnose anything.
Chevy Chase, Md.: I am an aspiring doctor, and I would like to know what were some of the things that made you score some medical students higher than others.
Emily Yoffe: They got a high score if they didn't stab me with their instruments. Most of them were nervous (a few impressively confident and skillful) and I thought it was better for them to admit their nervousness than pretend they weren't. One who was shaking kept saying to me, "Relax, relax!" even though I was very relaxed.
I hope you follow your dream!
Boston, Mass.: I enjoyed your piece about being a patient. Have you read any of George Plimpton's experiential books (he went to the Detroit Lions training camp in one)? Where do you draw the line in experiences you won't try?
Emily Yoffe: I haven't read the books, although I remember him well. I should go look them up.
If you've seen the column, I don't draw too many lines -- I was a street performer at the corner of 18th and M in downtown D.C. I am, however, a physical chicken. No washing windows on a skyscraper.
Herndon, Va.: Ms. Yoffe: I admire you taking on the daunting task of submitting to 23 examinations by fledging doctors. Would I be right in assuming more of the males seemed uneasy than the females? I would think a "first" exam is tougher if the "patient" is of the opposite sex.
Emily Yoffe: I wondered myself if there would be any sex difference and surprisingly, there wasn't. Some of the women were extremely uncomfortable and had no idea how to handle the gown and drape. Some of the male doctors knew exactly what to do to maintain some modesty and also do a cardio exam.
New York, N.Y.: Hi Ms. Yoffe,
I just completed my first year of medical school, and thoroughly enjoyed your column. I have had a few experiences with patient-actors, and have found them to be pretty absurd -- both the patient and the student know that this is a patently false and staged experience, yet we have to go through the motions. At the same time, however, I thought it was useful. Do you feel it was a worthwhile experience for the medical students? And did any of your students succumb to the temptation, that I've felt many times, to talk to you out of character?
Emily Yoffe: I hope it was worthwhile for the students! I think this is a great innovation because they get to mess up and be nervous without hurting or infuriating real patients. I did observe some of the other medical students and the standardized patients who were portraying an older person who had fallen, and the SPs seemed very convincing to me. A few of students acknowledged that they knew I was a "fake" but the exam was actually real. One student did ask me where the recording camera was
Washington, D.C.: Do you recommend joining this guinea pig program if you're an aspiring actor? Would this improve one's chances of being an extra on E.R.?
Emily Yoffe: I think it's great for the aspiring actor because after talking to the other standardized patients -- almost all of whom were actors --they said this was some of the best money they earned. Aside what what I learned about medical school, it reinforced my knowledge that the actor's life is hard.
As for ER, I think you have to be on a gurney in LA for that.
Baltimore, Md.: I am am a OB-GYN professor and have ben in the field for more than 25 years. Just for the record, no female physician undresses or performs a pelvic or a breast exam on a female patient without a chaperone. The point of the chaperone is not really to protect the patient. We assume, or hope, at least that medical student and medical professionals are not sexual deviants or predators. The chaperone is there to protect the medical student or professsional from an unwarranted accusation against which there is otherwise no defense.
Emily Yoffe: Fascinating. I never thought of it from the perspective of protecting the doctor!
Anonymous: Hi Emily,
I coordinate the standardized patient program at Midwestern University in Glendale, Arizona. I laughed a lot as I read your article. You sound like you are very good with the students. It takes a special kind of person to work well with student doctors, physician assistants, pharmacologists, podiatrists, dentists....
Emily Yoffe: Thanks so much. It was really fun and it brought up my own memories of stumbling around trying to become a journalist (a stage which some readers believe I've never passed). It was fascinating to see people who end up being god-like acting like baby ducklings.
Washington, D.C.: Did you get any feel for which students, if any, were completely unsuited for the profession, and would be better off in research or leaving medicine altogether? I wonder who tells these kids that. Their instructors, I hope. I was pleased to hear that the professors were watching the exams from outside the room.
Emily Yoffe: I was talking to the other standardized patients and they all say there is a category of medical student they hope only goes into pathology. There were a few who just had star quality, and a few others who seemed so in over their heads. But it's so early in their careers I felt I couldn't make a judgment that any of them should abandon medicine.
New York, N.Y.:"She said they weren't there to diagnose anything."
What does that mean? That if something serious was found nothing would be done?
Emily Yoffe: Yes! I did think: I've just had 23 physicials, and if I find out there is something actually wrong with me, I'm going to be really annoyed.
Nashville, Tenn.: I have my info session/interview on Aug. 7 at Vanderbilt Medical School. Any advice?
Emily Yoffe: If you're talking about advice for being a standardized patient (as opposed to being a med student) yes, if you're a woman shave your legs (I didn't the first day and was so embarrassed every time they checked my knee reflex) and wear nice underwear!
Columbia, Md.: I think that if any doctor had done what Dr. I did, I would have stopped the exam. I do have to wonder what his specialty is going to be and would hazard a guess that he will become a GYN.
Emily Yoffe: You're talking about the doctor who unsnapped and peeled off my bra in order to listen to my heart.
Actually he reminded me of the old joke, "What do you call the person who graduates last in the medical school class?"
Brooklyn, N.Y.: When I lived in England, I saw a magazine ad looking for "grousers." This is someone who assists hunters, and their dogs, by scaring up grouse out of the thickets so they can be shot to death. You might want to look into that for a future column.
Emily Yoffe: Oh, boy -- don't know if I have the stomach for that. Although I do have a beagle which is supposed to be a rabbit hunter. My beagle, thank goodness, is too incompetent to hurt a little bunny.
Washington, DC: Emily, I am a recent college grad who is huge fan of your column and have even joined the facebook group "Emily Yoffe Keeps Me Coming Back to Slate.com"! How goes your participation on Facebook recently? Do you enjoy the new applications? Have you made any new friends?
Emily Yoffe: Thanks so much.
Yes, I am the world's oldest Facebook participant. I have exchanged many emails with my new Facebook friends. As you mentioned, Facebook keeps adding new features and I have to ask my young Slate colleagues what they mean.
Durham, Maine: How come every one of your Human Guinea Pig pieces seems to involve you getting disrobed?
Emily Yoffe: That's not fair -- only 90 percent do!
For the vast majority (singing debut, oil rig visit, vow of silence, etc, etc) I stay dressed. The disrobing ones may be the most memorable (or disturbing).
Washington, D.C.: So after taking 23 physicals, you would now have to go take one from your doctor to find out if something is wrong with you?
In a country as lawsuit-happy as this one, I find it hard to believe they haven't been sued for something like that.
Emily Yoffe: I had to sign a waiver (what does it say about me that I don't remember reading the fine print). I'm sure I signed away my right to sue because a 2nd year student missed something nasty.
Just for the record, no female physician undresses or performs a pelvic or a breast exam on a female patient without a chaperone.: That's not true. My female doc conducts breast exams without a third party witness. Guess I'm lucky she doesn't assume I'll make a false accusation; glad that lady isn't my doc.
Emily Yoffe: Yes, I actually have been examined by both female and male gynecologists without a nurse in the room.
Cleveland Park, Washington, D.C.: Have you ever met the guy who hosts Dirty Jobs on the Discovery Channel? You two would probably hit it off. That, or you'd be competing to one up each other with your stories.
Emily Yoffe: I've seen the show and he's very clever. I think he'd win with that episode in which a snake sunk its fangs into his arm.
One who was shaking kept saying to me, "Relax, relax!" even though I was very relaxed.: Poor kid! I just get so sympathetic reading your funny description!
Emily Yoffe: I know. It really made me look at doctors differently and have more respect for what they do to get where they are. And the responsibility! In most professions, if you make a mistake you just have to apologize and fix it. If a doctor makes a mistake, a life can be ended.
Washington, D.C.: If they can't tell you if something was wrong, how did you know they missed "something nasty"?
I'd ask what it was, but ... nah.
Emily Yoffe: I meant I'd hate to find out after all my exams that I'm not in perfect health -- especially since I was told I had good mucosa and good bowel sounds.
Arlington, Va.: Thank you for the wonderful article. The Human Guinea Pig is my favorite series of articles. I sent this one to a friend who just started her internship at the Mayo Clinic. I hope it makes her laugh as much as I did!
Emily Yoffe: Thanks so much. I have heard from several medical students who said they recognized themselves and their classmates (the nervous laughers, the deadly with instruments, the smooth operators).
New York, N.Y.: I'm also a med student, and really enjoyed your piece. Though the standardized patient has become a big part of medical school (at least at my school), there are still some things we practice on each other for the first time—most notably drawing blood. Just be glad your physical didn't include any lab work....
Emily Yoffe: I don't think I would have signed up for 23 blood samples—I'd have to call the column Human Porcupine. As a patient, it's clear being able to draw blood requires a certain talent that not every medical professional has.
You're right, the standardized patient is becoming standard in medical schools, as the schools address the question of how to better develop doctors' communication skills.
Washington, D.C.:"My beagle, thank goodness, is too incompetent to hurt a little bunny." Careful, that's what I always said about my mildly retarded (but very sweet) cat. I was shocked speechless when he dispatched a mouse in the basement and laid its little corpse at the foot of my bed.
Your next gig should be in the janitorial industries. I'm curious about what people throw away, and what sorts of things they tuck under their desks.
Emily Yoffe: Good idea! I'll look into it.
Northeast, Washington, D.C.: Emily—thanks for volunteering to be a standardized patient. My wife just graduated from medical school and I'm glad she had people to practice stuff on besides me. I was surprised by the age of many of her classmates—many were not fresh out of college, having chosen medicine as a second career. Did you notice any difference in the manners of the soon-to-be doctors in relation to their age?
Emily Yoffe: You're a good husband. Hope you now get excellent, free medical care.
Most of the students looked about the same age—very early twenties. One guy seemed a little older and he was great—very skilled and not at all nervous. I did want to ask him what he'd done before medical school, but I wasn't supposed to break into my journalist mode.
Philadelphia, Pa.: My fiancee just finished her second year of med school, and I've noticed that the population of her class seems to be equally split between the half who, grading on a gentle curve, seem normal, and the half who are definitely aliens. (I recently had the experience of watching at a bar as two second years who must be from Neptune mimed out the female pelvic exam with their fingers in the air. Very gross, though bizarrely hard to stop watching.) What I've always wondered is whether the roughly normal group are actually better at doctoring than the weirdos. Among the would-be doctors who examined you, were basic social skills a good proxy for who did a good job and who did a dreadful job, or was there something else that made them successes or failures as physical examiners?
Emily Yoffe: Interesting and disturbing observations about your fiancee's classmate, because all of them will have a white coat with M.D. stitched on it.
But we've all had doctors whose personalities seemed, well, defective.
There seemed to be a general correlation between good social skills and eye contact and examination skills. But some really awkward ones actually did fine when it came to examine me.
Bethesda, Md.: Hi. This piece is great. I graduated from med school eight years ago and at that time we only had standardized patients for the male (urology) and female (gyn) exams. It was a great way to learn how to do a proper and thorough exam. My two "patients" were a nurse anesthetist (the man) and a midwife(the woman) so there was no BS-ing either one of them. The woman gave hints about how to make the examinee more relaxed during the exam ... talking to the patient the entire time you are examining her to let her know exactly what you are doing. Even though I now work in a different part of the body, I talk to my patients about what I am seeing the whole time. As a patient, I hate that silence while a doctor is looking and then that painful pause between the end of the exam and when they tell you what's up. Enjoy your exams and thanks from those of us that you are training.
Emily Yoffe: Thanks and excellent points about talking. Maybe not every patient likes it, but I really appreciate when a doctor says, "I'm feeling for your liver" etc. I'm fascinated that an M.D. has a critique about how other doctors go about their examination.
The people who are trained to be genital/urinary standardized patients really do instruct the young doctors in how to perform the exam, what hurts, when to press harder etc. What an amazing job!
Kingstowne, Va.: Can I receive free treatment by volunteering to be a patient?
Hmmm... on second thought....
Emily Yoffe: Go with that "second thought"
Clinton, N.Y.: I love you, Emily Yoffe! You always bring to light the funny, telling detail and your Dear Prudence advice is fab.
Suggestion for a Human Guinea Pig gig: Do a cooking class, not at CIA or the like, but at a Y, or some such more modest operation. I am a nervous wreck in the kitchen, and have always wondered whether a course would make me any more competent or confident.
Emily Yoffe: Thank you so much. I'm also one of those freaked out cooks. I'm so glad I don't have an open kitchen, that way my guests don't see me bleeding and crying on their food.
I think going to a really serious cooking school would be a fun Guinea Pig.
New York, N.Y.: Have you ever considered backup singer for jingles? Every time I hear an add with a jingle that involves multiple singers I can't help but to imagine them in the recording studio singing these cheesy/odd lines.
For example the loan ad for 8-6-6-66-Faster, "You've got the Green Light." And these are good singers. Are they professional backups, karaoke flies, American Idol rejects? I'd like you to find out. Thanks.
Emily Yoffe: I did make my singing debut at Strathmore Hall for Human Guinea Pig. My editor said listening to it was the aural equivalent of watching the Hindenberg explode.
Gaithersburg, Md.: I really enjoy the "Human Guinea Pig" series. I was wondering how the "Dear Prudence" experience is different for you. Certainly the readers seem more ... um ... pointed ... in their opinions.
Emily Yoffe: They are different, but I love the reader feedback from Prudence because people will immediately tell me if they disagree (strenuously) with my advice. I learn a lot from them.
A good bedside manner is nice: But I'm much more interested in a knowledgable doctor; I'd gladly sacrafice some social skills for a top notch surgeon. In fact, I don't think one person can be all, so I'd rather have the doctoring skills. I have my own friends on the outside, thanks. What I need is an orthopaedic surgeon, and if he's a little low on the social skills, that's okay, you'd have to have a bit of an ego to be able to cut into people and save lives.
Emily Yoffe: Good point. But I know from (too many) friends who have cancer that it's very disturbing if your oncologist does not make a human connection with you. With your surgeon, during most of your relationship you're unconscious. With other doctors, you want good medicine, absolutely, but feeling your are a real person to your doctor is also important.
Emily Yoffe: Thanks everyone for your fascinating questions and good Human Guinea Pig suggestions!