In Simulation, Student Detects Previously Overlooked Condition
April 18, 2016
When Jenny Retig entered a routine simulation experience back in the fall she had no idea she’d detect a serious health condition previously overlooked by licensed health care providers.
Retig, a second year physician assistant student, detected a nodule on the neck of one of Drexel’s standardized patient actors during a simulated physical exam – a standard requirement of the curriculum. As a result of Retig’s findings, the standardized patient actor, BA Bigham, was diagnosed and prescribed surgery to have the potentially life-threatening nodule removed.
“I’ve worked with standardized patient actors, including Ms. Bigham, before but didn’t think it was going to end this way,” said Retig. Standardized patients are professional actors that faculty hire and train to enhance the development of interpersonal, clinical and assessment skills in undergraduate and graduate students. Standardized patients exhibit specific symptoms during scripted sessions, and are a cornerstone of the College of Nursing and Health Profession’s approach to health care education.
“I’ve been a standardized patient since 2007 and at Drexel since 2011, and this is the first time anyone has found something medically wrong with me,” said Bigham. “I’m really grateful that she [Retig] had the self-confidence to disclose this information and cared enough to share it.”
Prior to the simulation both Retig and Bigham were given specific prompts and objectives. It was Retig’s responsibility to solicit key information, record a medical history and administer exams based on the information Bigham was required to share.
When Retig examined Bigham’s neck she noticed an unusually large mass on one side – something she was not expecting to find and not part of the patient profile for the simulation. Startled by her discovery, Retig asked to repeat the exam to confirm the mass on Bigham’s neck.
“My objective was to collect her medical history and tailor my exam to that information,” said Retig, “but they usually don’t have or experience the symptoms they’re disclosing.” After realizing there was something medically wrong with Bigham, Retig reported the information to faculty then made a judgment call on how best to proceed.
“Since we are students we’re not supposed to advise what we think patients should do medically,” said Retig. “I didn’t want to make her nervous if there wasn’t anything to worry about, but I also didn’t want to ignore the mass in case it was a serious medical condition.”
After reporting the information to simulation faculty and Rosalie Coppola, the supervising instructor, Bigham was advised to return to her primary care physician for additional testing. Another physical exam – followed by an ultrasound and CT scan – confirmed that Bigham did, in fact, have an abnormally large nodule on her thyroid, and that it was encroaching on her trachea.
A biopsy revealed that the nodule was benign, but that it needed to be removed based on its size, position and potential threat to Bigham’s trachea and carotid artery. Bigham underwent surgery in late March to have the nodule removed and is currently in recovery.
“The diagnosis was startling to me since I’m a healthy person – this came completely out of the blue,” said Bigham. “I’ve never felt any symptoms, and the tests administered by my health care team never indicated there were issues with my thyroid.”
Despite Bigham’s positive attitude, her experience raises significant concerns about the effectiveness of primary care treatment many patients receive. For Rosalie Coppola, Retig’s instructor and Associate Clinical Professor in the Physician Assistant Department, Bigham’s experience is representative of a shift in primary care that can result in missed diagnoses.
In Coppola’s opinion, many health care providers tend to recommend lab work and testing over physical exams, and prescribe treatment plans based on questions rather than actual exams.
“Physical exam skills are so important, especially at a time when they’re becoming ancient history,” said Coppola. “If you don’t look, feel and touch you won’t find anything.”
“What makes PAs so important as part of a patient’s health care team is our ability to take a detailed medical history and implement a thorough physical exam. We’re able to find things because we know where to look for them,” said Coppola.
With over 24 years of experience in physician assistant education, Coppola knows what’s needed to equip physician assistants with essential skills and core competencies to make them successful practitioners.
“We train our students to err on the side of caution and trust their instincts enough to consult with their supervising physician if they think something is wrong,” said Coppola. In Bigham’s situation Retig did just that, despite there being universally accepted policies regarding a student diagnosis during simulation.
“There aren’t clearly defined rules, but as an education and health care provider, I felt it was ethically the right thing to do,” said Coppola regarding Retig’s discovery. “I believe she followed all the right steps in reporting what she found.”
Given such an ambiguous situation, Retig was concerned about the appropriate chain of command to follow. “It wasn’t a question of whether or not I was going to say something, but I wanted to make sure that what and who I reported to was correct.” At the end of the day, Retig made the right call.
Despite the abnormal and threatening details of the simulation, Retig, Coppola and Bigham are all able to find a silver lining.
“As a student you feel intimidated and may lack confidence, but I feel more confident in my abilities and capacity to enter the provide role,” said Retig. Coppola agrees, and is proud that a student was able to address the situation with such maturity and poise.
Well, she believes that Retig needs to be recognized as a student that takes her education very seriously and demonstrates a caring demeanor.
“I can’t tell you how thankful and grateful I am for this young lady. It’s possible she could have saved my life.”
Update: Ms. Bigham’s surgery was successful. She is currently in recovery and is not experiencing any pain. She fully intends to return to Drexel as a standardized patient, and continues to express gratitude for Retig, Coppola and the Physician Assistant Department.