Where jargon must have been invented.
[The Tower of Babel, via wikimedia]

One of the things I really care about as an SP is the use of accessible language. It's very easy for SPs to become accustomed to medical terms and concepts that a "real" patient would be uncertain of or that are different in the patient's daily context. I believe addressing health literacy makes a positive impact on the relationship between doctors and patients and provides better outcomes for patients.

My advice to learners is to use "living room language," or language targeted to a 3rd-grade reading level. How would they explain this to a 10-year-old? A patient will usually give clear cues if they feel they can handle more complex language.

At this point most students I work with know better than to use abbreviations or really ridiculous medical jargon. But there are still words students use as if they are common knowledge. Some patients might be able to understand them in context. But even if they do, every time a patient has to spend mental energy interpreting a doctor's question, that reinforces the power differential between them. The greater the power differential, the more difficult it is to establish trust and safety. More importantly, a patient may not actually understand what a doctor has asked -- but attempts a reasonable guess so s/he doesn't look stupid, and then the doctor mistakenly believes they share an understanding when they really don't.

So when a student uses a word I think a patient might have trouble immediately understanding, I have a few ways to respond while still staying in character depending on the school, the student, or the scenario:

•  a slight pause before I answer
• a questioning look
• an ambiguous answer based on the more common meaning of the word
• "What does that mean?" or "What do you mean?"
• "I don't know what that means."
• "You mean [restates question in a patient-centered way]...?"
• "Well, I don't know what that means, but [answers question as if student had asked it in a more accessible way]

Some schools don't want SPs to react when a student uses technical language for a variety of reasons: because they're being taught to use precise language like that, because it eats up precious time in a short encounter, etc. And because SPs are inconsistent in reacting to technical language, if you are the SP who looks confused when the student keeps insisting on using the word "palpation," students may think you are deliberately playing dumb.

But I feel like to best prepare students to communicate with their patients, students need to practice translating the language they are learning into a language patients understand. My job is to remember what it was like the first time I encountered an odd word and react in a similar way for all encounters afterwards. Allowing students to shortcut this skill in SP encounters sets them up badly when they encounter patients in clinics.

Reset

Okay, time for feedback.
[King Lear Mourns Cordelia's Death, via wikimedia]

A friend sent me an article: "How Actors Create Emotions." I'm always fascinated by how quickly SPs reset between encounters. No matter what kind of encounter we have with a student, when they return for feedback we are ourselves again. Or, in cases where there is no feedback, the next student comes in and we start all over again. We are the same but different up to 20 times a day.

Not all SPs are actors. I am, and I love the depression cases, the bad news cases, the uncomfortable cases, the angry patient cases. But each of them takes its toll. In my case, the louder and more energetic the patient, the harder it is for me to sustain. But other SPs feel tired and lethargic after a day of being a depressed patient.

The author compares two approaches to modern theatre: "Strasberg was much more interested in actors working from their real lives and real pain, whereas Meisner thought that was "psychotherapy and had no place in acting.""

I guess I've always leaned in the Strasberg direction; I've never been been a Meisner fan. In fact, one of the things I very much value about SP work is how it allows me to discover things about myself. As I do, I can give better feedback to students about how to help me feel safer and more respected as a patient. 

So the more I put into the role, the more insight I can develop for students. But allowing for self-analysis and feedback helps keep the roles from becoming too true for me. From the article: "In art you have to be responsive. Things have to get in so that they can get out, and you can’t live the way you do your art or you’d be wounded every second.” SP work is better than live theatre in this way precisely because you get the chance to reset yourself. In theatre, repeating the same script with the same actors for 6+ weeks can wear the emotional groove deeper with each rehearsal and performance. But to be a good SP I need to respond to what a particular student is giving me at a particular moment, so every student is a new opportunity for exploration and discovery.

The value of SPs

Core values.
[Apples and chestnuts, via wikimedia]

I remember with great clarity a conversation I had with a faculty member who was unconvinced of the value of SPs. As a teacher at a school that has a reputation for being patient-centered, he felt non-empathic applicants self-selected out, which meant they could focus on teaching the physical skills to the students who were accepted.

But (said I) even with the best students in the world, skills decay over time unless they are reinforced and rewarded. Medical school is almost deliberately overwhelming. Faced with competing priorities, it makes sense for students to focus on the priorities that are rewarded by the system. If grades, clinical experience, and service are what the institution rewards, then patient communication skills become less visible and important. Starting with good students just means the slide is less precipitous.

So for all their other virtues, at the most fundamental level SP encounters help remind students that patient communications skills matter. They indicate that the institution still values those skills as part of its medical education. I don't think this should be limited to the first two years, though: SPs should be an integral part of a professional medical education at all stages, including after licensure. Practice may not make perfect, but you are significantly more likely to maintain a skill if you practice it than if you don't.

Empathy first

Show me yours and I'll show you mine.
[Maria mit flammendem Herz, via wikimedia]

If I could teach medical students only one thing as an SP, it would be to provide empathy first. Nothing makes me feel more heard and understood than empathy right at the beginning of the encounter.

What usually happens:

student: "What brings you in today?"

SP: "I have chest pain/this weird rash/trouble sleeping."

student: "When did that start?"

What would make me feel ten times better:

student: "What brings you in today?" 

SP: "I have chest pain/this weird rash/trouble sleeping." 

student: "I'm sorry to hear that. So when did that start?"

Extra credit! Add validation:

student: "What brings you in today?" 

SP: "I have chest pain/this weird rash/trouble sleeping." 

student: "I'm sorry to hear that. I'm glad you came in. So when did that start?"

Doctors have the most ability to influence patient trust within the first few minutes of the encounter. As soon as the doctor has offered me empathy for my current pain and validation for coming in, I feel like the doctor has heard my concern and is taking it seriously. At that point, I can feel myself relax.

Setting the standard:
If a checklist item asks the SP to evaluate empathy, that empathy should be some sort of verbal statement about the pain the patient is currently experiencing within the first minute of the encounter.