SPs singing a hit song about debriefing techniques.
[The Mark IV via wikimedia]

I'm still working as an SP at a variety of programs, trying to find better ways to articulate the wonderful and awkward and invisible ways we teach communication skills to a variety of learners.

I don't have nearly as much time to write as I'd like. But reviewing some of what I wrote 5 (!!) years ago, most of it still is relevant. One of my major goals was to resolve the ambiguity and friction I felt when clarity was lacking, especially when rating "soft skills." It was highly useful to create standards for myself so I could make conscious choices when a program didn't have its own. Much of my current feedback/debrief is based on the work I did here to truly understand and articulate vague communication items and the systems in which I work. So here are some of my greatest hits, the ones that still have great influence on me and that describe the kind of details I am looking for in encounters:

Communication:

• Empathy first
• The power of the power differential
• Core value: Physical Autonomy
• Core value: Consent
• Lost in Translation
• Words to Watch
• Answering open-ended questions
• How are you today?
• Pain scales
• Communicating sincerity
• Using collaboration with patients
• You're going to be OK
• Delivering a diagnosis
• Teach back
• Wrapping up
• Time management skills
• Why "Is that okay?" is not okay
• Does that make sense?
• Uptalk?

Feedback:

• The value of student self-reflection
• Feedback hierarchy
• Feedback models: When you did X, I felt Y
• Feedback models: Feedback Sandwich
• The point of greatest vulnerability
• Yes, yes: using agreement in feedback
• Have you seen something like this before?
• Turning it around
• I would also like to write about other feedback models, like "Debriefing with Good Judgment," Advocacy/Inquiry, +/∆, PEARLS, GAS, or the Curious Empathy model (which is the model I choose when I have a choice).
  

Exams: 

• Neuro exam checklist
• HEENT checklist
• Abdominal exam checklist
• Strength testing
• Ungowning instructions
• Depression

Work environments:

• Herding cats: scheduling SP jobs
• Irregular standards: working at multiple schools
• Irregular standards: getting paid
• Irregular standards: training
• Irregular standards: SP discipline
• Case preparation
• Modesty & invasiveness in SP encounters

Profession:

• History lesson
• 1 year!
• Overstepping one's bounds

SP web series!

Standardized: a web series by SPs, for SPs. Watch the pilot below:

Elderly simulations

An elderly patient patiently waits for her appointment.
[Portrait of an Old Woman via wikimedia]

Some people still say you can't practice empathy, that people either have this as a skill or they don't.  I disagree, which is why I like these elderly simulations in Poland:

Medical student Ludwika Wodyk fumbles her way slowly down the stairs, her movements encumbered by heavy strapping around her limbs and body, her vision distorted by special goggles. She is one of a group of medical students in Poland being given the chance to experience first-hand how it can feel to be an aging patient.

Empathy is something that can be taught, or at the very least, experienced. For many people, empathy is highly contextual, so direct experience with a problem can often give them insight into the barriers or complications of a particular population. This brings benefits like understanding, tolerance, and more creative problem-solving when the same circumstances arise again.

Elderly simulations can also be found in Britain and at MIT.

Extra credit:
When I roleplay older patients, I usually focus on the visual aspects. In future scenarios I want to pay more attention to the physical aspects and give feedback from the perspective of a person who might also have mobility, sight and hearing challenges as well.

Quote of the Day

[William Osler photograph via wikipedia]

"It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has."

William Osler

Osler was one of the four founding professors of Johns Hopkins Hospital. He established the practice of residency. Before Osler, med students could go on to be doctors without having seen a single patient!

Bedside Manner

Yes, I want to see more cross-pollination and artistic collaborations like Bedside Manner!

From the artist's website: "Bedside Manner is a series of photographs and an 18-minute video that explores the little-known world of standardized patient simulations. Standardized patients (SPs) are professional medical actors who are trained to present particular sets of symptoms in order to help medical students improve their diagnostic skills and bedside manner. Routinely, SP encounters are filmed and evaluated by medical professors who observe the interaction of student and medical actor through a one-way mirror."

I am delighted Corinne May Botz got permission for this series. Botz is also the author/photographer of "The Nutshell Studies of Unexplained Death," which explored the groundbreaking crime scene dioramas of Frances Gleaner Lee in the 40s and 50s.

I really wish I could watch the video, which doesn't appear to be available on her site or linked from the New Yorker. According to Botz, the video "deconstructs a real-life standardized patient simulation. It also creates a complex portrait of the neurologist Dr. Alice Flaherty, who plays herself as a doctor, standardized patient and real patient." Intriguing!

I think I am most interested in exploring this further: "...acting and staged representations inform the interaction between patients and doctors in important ways. In order to express their suffering, real patients must learn how to act in doctors' offices." This is very insightful. Reminding learners that patients are "acting," too, may be of use to them. The more learners are able to demonstrate empathy, validation, confidence, respect and autonomy, the less likely patients are to feel the need to "perform" to demonstrate their distress.

In fact, I am strongly reminded of a blog post called "Performance Anxiety" about how an obese patient feels the need to be "terrifically cheerful" in order to receive adequate care. "...being cheerful and upbeat simply works to get a better quality of care in almost every instance. But it’s also enormously taxing, because it is, after all, a performance. Going in for my ultrasound appointment, I was nervous as hell, but I also knew that as soon as I met with the wand-wielder I’d have to push all that worry away and take on a lighthearted, friendly, cheerful persona if I wanted to be certain I’d be treated like a whole person... this pressure to perform under what are at best extremely uncomfortable circumstances does add an additional layer of stress... I resent having to put this happy-fat-lady caricature on. But it’s the most reliable method I know for securing good customer service when I’m meeting a specialist or any new-to-me medical professional for the first time."

Using collaboration with patients

An SP and a learner collaborate together.
[The Duet via wikimedia]

Collaboration is a tool learners can use to reduce the power differential and invite the patient into the conversation.

Collaboration engages the patient with questions that explicitly offer the patient input into treatment, insight into the illness, or the ability to set the agenda or control their own experiences. Learners can always collaborate with the patient even in simple encounters:

• What else did you want to talk about at today's visit?
• What/why do you think this is happening?
• What do you think about [X]?
• What questions do you have so far (not just as a wrap-up question)
• Is there anything else I should know about your condition?
• We can stop the physical exam at any time.
• How does that plan sound?

Collaboration is especially vital in lifestyle modification discussions, and open-ended questions are the most effective.

• How could you improve your diet?
• How could you add more vegetables to your diet?
• How could you get more exercise in your day?
• What activities are most interesting to you?

However, a collaborative statement is not a supportive statement. So if the learner says "We'll do this together" or that "I'll be here every step of the way," that's nice and an effective use of reassurance/support, but it's not collaboration. And as I've written before, "Is that OK?" is not a collaborative (or good) question.

Here's an example of how to classify statements that could occur in a smoking cessation case, for example:

• Statement: I tell my patient to start slow, just one cigarette a day.
• Statement: That's something you could do.
• Closed collaboration: Will that work for you?
• Open collaboration: How does that sound?
• Open collaboration: What questions do you have about those recommendations?
• Open concrete collaboration: How many cigarettes do you think you would like to try cutting back on per day?
• Supportive: We'll do this together. We have lots of resources to keep you on track.

Homework:
Keep an ear out for collaborative statements in your next encounter. What could the learner do to invite you into the conversation?

Wit

Happy holidays! Enjoy Emma Thompson in "Wit" while you're on break. "Wit" won the 1999 Pulitzer Prize for drama. It's funny and awkward and moving. Also: poetry! As someone who has done countless consent and DNR scenarios, this is a tough (but interesting! and powerful!) screenplay to watch; I can't imagine what it must be like if you have had cancer or lost someone to cancer.

Bonus gift: "UVM Medical Center hosts production of "Wit". SPs performing in a lecture hall! I wish I worked at an institution where this was possible.

"Wit," which won the 1999 Pulitzer Prize for drama, comes to Burlington thanks to another woman named Vivian — Vivian Jordan, a Shelburne resident who plays the lead role and whose profession merges the performing arts with the medical arts. Jordan works at the hospital as a “standardized patient,” which means she acts out roles for medical students learning how to diagnose illnesses. It brings awareness of end-of-life issues and spark discussion on the complex nature of dying in the Pulitzer Prize-winning play.