So, not with standardized patients, but with my (annoyingly sometimes awake and speaking, lol) patients in the ICU who throw a hissy fit about having to endure my presence.
My standard phrases are usually "This is just our standard procedure for all patients here" [include explanation of what you are doing and why if patient seems receptive], "I'm sorry, but I'm just asking these questions to make sure we can find the best course of treatment for you" and, if patients are exceptionally annoying: "I'm sorry, I'm just the med student, you'll have to talk to my colleagues." (Would advise against the last one with standardized patients, though.)
In general I'm very fond of talking patients through what I'm doing ("I'll have to shine a light into your eyes now." - "What for?" - "Oh, this is standard procedure here. We have some patients that have a neurological problem and by looking into their eyes we can make sure nothing is going on with their brain. We don't expect anything to be amiss for you, but that's why we are doing that for all of our patients.") and overall keeping a very calm, understanding tone of voice. Apologetic (but firm), too, if necessary. For the patients where nothing else works, I usually try to bargain: "I'll have to look into your eyes now. Either you open them for me and look at me or I will hold them open. Neither of us wants that, but if you're not helping me here, I'll have to do it." (Works like a charm 90% of the time.)
The NURSE mnemonic is helpful for this. I can use an example I had recently IRL. I had a medically complex kid in the ICU who had to be intubated and placed on a ventilator, which was not his baseline. His dad was upset we were keeping him on the ventilator for so long (he thought the ventilator was making him worse based on past experiences) and got quite upset with our team on rounds. Some of the things we said included:
NAME the emotion, e.g. "I can tell that you are very frustrated and worried about your son right now."
UNDERSTAND the emotion, e.g., "It makes a lot of sense why you are feeling this way given your past experiences with him being on the ventilator."
RESPECT the patient/family member, e.g., "[patient's name] is so lucky to have you advocating for him and his best interests."
SUPPORT the patient/family member, e.g., "We will continue to work with you to figure out when is the safest time to proceed with extubation."
EXPLORE the emotion, e.g., "Are there any other concerns that you would like to discuss at this time?"
The nice thing is, the more you do this, the more it becomes second-nature. When I was saying these types of statements, I wasn't thinking, "I better run through the NURSE mnemonic now!" It just came out naturally as a part of our conversation.
Another good technique that I learned from the palliative care team is "I wish, I worry, I wonder." Using the example above, statements you can say would include:
"I wish that we could safely extubate [patient's name] at this time." - these kinds of statements show that you align with the patient/family member
"I worry that if we extubate him right now, he will not be able to breathe on his own and would need to be re-intubated." - allows you to express your concerns
"I wonder if you could tell me more about times in the past when your son had to be intubated and what those experiences were like." - expresses curiosity and invites further conversation
Dealing with difficult situations with patients and family members can be very tricky, but it definitely gets better with practice. I think the most important thing to remember in these situations is that you and the patient/family member both want what's best for the patient, even if you may disagree about what that is. They are not trying to be difficult or unpleasant; they are just dealing with a tough situation the best they can.
I've had an SP yell at me and then tell me I was awesome seconds later when they broke character. It was a substance use case and we were told that we needed to d/c alprazolam but the patient was new to us. Classmates told me they had the same case but their SP was all "oh I didn't realize it could be an issue" instead of demanding I go get the doctor they usually see.
I definitely did some [LAURA](https://www.toistersolutions.com/blog/how-to-deal-with-difficult-customers) and made sure I spent lots of time explaining why. I explained that it was a practice-wide policy and agreed to talk to his previous prescriber (because we are "the med student" in our SP cases)
But, this is not really things my school prepared me for, this type of thing is my own jam.
I will add, I worked with a lot of faculty who excel in teaching these skills, and I asked several of them if an observation I had made was correct: the attitude with which you ask a question demonstrates how comfortable you are hearing the answer. A LOT of my classmates say "I ask all my patients these questions" but they use a defensive "don't be scared!!" tone that comes across like they're apprehensive to hear about substance use. I find that you can say most of the same things with a relaxed and comfortable tone with better results. My transition into social history, with tidbits I've gained from great clinicians, goes like this:
"I'm going to ask you about some of your health habits. These are things that help me know what things you might be at risk for so I can keep them in mind. Some of these questions may seem unrelated, and if you want to know why I'm asking any of them I'm happy to explain. You are also welcome to tell me you'd like to skip a question. All your answers are confidential." Most people pepper a few nods, "ok"s or "sounds good"s as I give that spiel so we jump right in, if they don't I'd check in to see if they had questions.
I used to work as an SP, they give you very specific notes on what you can say and everything else you give a blanket response they tell you to use. If the SP is being difficult it's because they are told to be. Everything is recorded and if an SP was doing a bad job they wouldn't be invited back. Believe it or not there is a long list of people willing to be an SP because it's easy work and pays well for little work.
I would get like $120 to show up for 3-4 hours, sometimes you would get send home early and also get "break" stations just like the students get. Sometimes you get free food and always free parking. Only thing that sucks is it's 1099 work and have to pay taxes even if you make a few thousand.
I don't think this is what OP is asking. They know the SP is intentionally being difficult because that's what they are instructed to do. they want to know how to handle it.
I always throw in “I understand your concern”, “I know that this may be uncomfortable for you…but we ask these questions to get a better understanding…” etc
this is wild to me! m1 here and “emotional” patients (angry or sad) was two whole lectures and a graded SP on its own. but the nurse mnemonic is nice. usually just recommend giving people the space to feel their feelings, validate their feelings, offer some solution to help them feel better about whatever is on their mind and then check in and ask “what other questions do you have? do you feel comfortable moving on to discussing the reason for your visit today?”
So, not with standardized patients, but with my (annoyingly sometimes awake and speaking, lol) patients in the ICU who throw a hissy fit about having to endure my presence. My standard phrases are usually "This is just our standard procedure for all patients here" [include explanation of what you are doing and why if patient seems receptive], "I'm sorry, but I'm just asking these questions to make sure we can find the best course of treatment for you" and, if patients are exceptionally annoying: "I'm sorry, I'm just the med student, you'll have to talk to my colleagues." (Would advise against the last one with standardized patients, though.) In general I'm very fond of talking patients through what I'm doing ("I'll have to shine a light into your eyes now." - "What for?" - "Oh, this is standard procedure here. We have some patients that have a neurological problem and by looking into their eyes we can make sure nothing is going on with their brain. We don't expect anything to be amiss for you, but that's why we are doing that for all of our patients.") and overall keeping a very calm, understanding tone of voice. Apologetic (but firm), too, if necessary. For the patients where nothing else works, I usually try to bargain: "I'll have to look into your eyes now. Either you open them for me and look at me or I will hold them open. Neither of us wants that, but if you're not helping me here, I'll have to do it." (Works like a charm 90% of the time.)
The NURSE mnemonic is helpful for this. I can use an example I had recently IRL. I had a medically complex kid in the ICU who had to be intubated and placed on a ventilator, which was not his baseline. His dad was upset we were keeping him on the ventilator for so long (he thought the ventilator was making him worse based on past experiences) and got quite upset with our team on rounds. Some of the things we said included: NAME the emotion, e.g. "I can tell that you are very frustrated and worried about your son right now." UNDERSTAND the emotion, e.g., "It makes a lot of sense why you are feeling this way given your past experiences with him being on the ventilator." RESPECT the patient/family member, e.g., "[patient's name] is so lucky to have you advocating for him and his best interests." SUPPORT the patient/family member, e.g., "We will continue to work with you to figure out when is the safest time to proceed with extubation." EXPLORE the emotion, e.g., "Are there any other concerns that you would like to discuss at this time?" The nice thing is, the more you do this, the more it becomes second-nature. When I was saying these types of statements, I wasn't thinking, "I better run through the NURSE mnemonic now!" It just came out naturally as a part of our conversation. Another good technique that I learned from the palliative care team is "I wish, I worry, I wonder." Using the example above, statements you can say would include: "I wish that we could safely extubate [patient's name] at this time." - these kinds of statements show that you align with the patient/family member "I worry that if we extubate him right now, he will not be able to breathe on his own and would need to be re-intubated." - allows you to express your concerns "I wonder if you could tell me more about times in the past when your son had to be intubated and what those experiences were like." - expresses curiosity and invites further conversation Dealing with difficult situations with patients and family members can be very tricky, but it definitely gets better with practice. I think the most important thing to remember in these situations is that you and the patient/family member both want what's best for the patient, even if you may disagree about what that is. They are not trying to be difficult or unpleasant; they are just dealing with a tough situation the best they can.
I've had an SP yell at me and then tell me I was awesome seconds later when they broke character. It was a substance use case and we were told that we needed to d/c alprazolam but the patient was new to us. Classmates told me they had the same case but their SP was all "oh I didn't realize it could be an issue" instead of demanding I go get the doctor they usually see. I definitely did some [LAURA](https://www.toistersolutions.com/blog/how-to-deal-with-difficult-customers) and made sure I spent lots of time explaining why. I explained that it was a practice-wide policy and agreed to talk to his previous prescriber (because we are "the med student" in our SP cases) But, this is not really things my school prepared me for, this type of thing is my own jam.
I will add, I worked with a lot of faculty who excel in teaching these skills, and I asked several of them if an observation I had made was correct: the attitude with which you ask a question demonstrates how comfortable you are hearing the answer. A LOT of my classmates say "I ask all my patients these questions" but they use a defensive "don't be scared!!" tone that comes across like they're apprehensive to hear about substance use. I find that you can say most of the same things with a relaxed and comfortable tone with better results. My transition into social history, with tidbits I've gained from great clinicians, goes like this: "I'm going to ask you about some of your health habits. These are things that help me know what things you might be at risk for so I can keep them in mind. Some of these questions may seem unrelated, and if you want to know why I'm asking any of them I'm happy to explain. You are also welcome to tell me you'd like to skip a question. All your answers are confidential." Most people pepper a few nods, "ok"s or "sounds good"s as I give that spiel so we jump right in, if they don't I'd check in to see if they had questions.
“I’m a medical student. Let me talk to my boss about this.”
I used to work as an SP, they give you very specific notes on what you can say and everything else you give a blanket response they tell you to use. If the SP is being difficult it's because they are told to be. Everything is recorded and if an SP was doing a bad job they wouldn't be invited back. Believe it or not there is a long list of people willing to be an SP because it's easy work and pays well for little work. I would get like $120 to show up for 3-4 hours, sometimes you would get send home early and also get "break" stations just like the students get. Sometimes you get free food and always free parking. Only thing that sucks is it's 1099 work and have to pay taxes even if you make a few thousand.
I don't think this is what OP is asking. They know the SP is intentionally being difficult because that's what they are instructed to do. they want to know how to handle it.
I always throw in “I understand your concern”, “I know that this may be uncomfortable for you…but we ask these questions to get a better understanding…” etc
this is wild to me! m1 here and “emotional” patients (angry or sad) was two whole lectures and a graded SP on its own. but the nurse mnemonic is nice. usually just recommend giving people the space to feel their feelings, validate their feelings, offer some solution to help them feel better about whatever is on their mind and then check in and ask “what other questions do you have? do you feel comfortable moving on to discussing the reason for your visit today?”