“Jessica, hello! How are you doing today?”
Jessica wasn’t real. She was a standardized patient, a fictional character created by my medical school for training purposes. After entering the clinical wards, I quickly drew this distinction between reality and ‘make believe.’ With Jessica, I could make mistakes. I could flub my words, pause the interview, say something insensitive, or forget to ask a pertinent aspect of the history with no real recourse. I shut the door behind me and entered the simulation.
“I have burning in my vagina.”
She spoke quietly and with a flat affect, and I was quick to adjust my voice to match hers. This week, our simulation involved human trafficking of a minor. First, we were tasked with forming a patient-doctor relationship and determining the pathology behind our patient’s pelvic pain. Then, after establishing a foundation of trust, we were asked to assess our patient’s willingness to leave her abuser. The total time allotted with our patient: 15 minutes.
“Well, that’s no good. Tell me, when did this start?”
I leaned in and composed a look of concern beneath my mask. Navigating patient interactions was a skill I had yet to master. Early eye contact, leaning in, and name repetition seemed to work well during my first few weeks on the wards. But every patient was different, and I hadn’t learned all the subtle cues to guide my behavior. Furthermore, the artificial nature of this interaction added yet another layer to be traversed.
I moved quickly to obtain the pertinent history. Vaginal discharge, fever, difficulty walking, a one-week duration. Textbook symptoms for pelvic inflammatory disease, a diagnosis my preceptor hinted towards in the hour leading up to my simulation. I finished asking about her symptoms and looked at the clock. 7 minutes left, and I had yet to triage the severity of her sexual abuse.
“Jessica, we’re on the same team. This might be an infection. Would you be able to tell me about your sexual activity?”
Our conversation went back and forth. She initially rejected the premise of my question, questioning its relevance. Then, after gentle encouragement, she began relinquishing unwanted past sexual contact with over 10 men over the past year. I nodded and listened.
“I see. Why do you have all these sexual contacts if you have a boyfriend?”
The words left my mouth before I could filter them. Much too judgmental, I thought. I looked over to the clock: 2 minutes left.
“My boyfriend is waiting I really need to go.”
“Wait Jessica before you go I need you to know your options.”
“I don’t have options. I must go.”
“Wait please it’s my job to help you. We can always go to the authorities.”
“No I don’t want to do that. Give me the medication so I can go.”
I nodded, told her I understood, and obliged her request. The interaction ended, and the feedback I received from my preceptor and the standardized patient was relatively positive: I had established a good patient-doctor relationship within the 15-minute period. I had encouraged the patient to open up to me, and I had successfully diagnosed pelvic inflammatory disease. My preceptor was satisfied with the interaction, and yet I had let my patient walk away without successfully solving her underlying problem.
With the sense of defeat still lingering, I entered the session debrief room along with roughly 10 other students. During the next 30 minutes, a faculty member spoke about the complexities of human trafficking, and the limited role physicians have in preventing and reporting potential sex crimes. The desire to help the patient must be tempered by an understanding of reality, no matter just how uncomfortable this reality may be.
I’ve only spent 3 months working consistently with real patients, and yet my interaction with Jessica felt more genuine than any of my other standardized patient interactions. This isn’t because I’ve worked with sex trafficked patients before; it’s because I’ve often left my patient’s room feeling defeated. People go to the doctor with the expectation that we will be able to solve their problems, but all too often we find ourselves unable too. The patient with metastatic ovarian cancer, the patient with systolic heart failure, and the patient with an irreversible cognitive impairment all still look to us for help, even when there is only so much help we can provide.
My preclinical years were filled with repetitive test taking, intensive studying, and literature review. Discounting these aspects of medical education would be a wasted effort; knowledgeable physicians are competent physicians. Even so, I still wish I had been introduced to more Jessicas before starting my rotations.
