[Portrait of Henry Ford via wikimedia]

"You can't build a reputation on what you are going to do."

Henry Ford

When I give students feedback about empathy or rapport, sometimes they respond by saying, "Oh, I'm so much better in clinic" or "I'm different with real patients" or "I don't do well when I'm being observed." But I can't give feedback on skills I don't observe.

Pelvic anthem

If "8 Miles Wide" isn't the anthem for pelvic models/educators everywhere, it should be! By the way, this song is not at all safe for work, not even a tiny bit.

"It's not my vagina! It's our vagina!" Godspeed, you brave and valiant vaginas.

Feedback models: When you did X, I felt Y

Let X=X.
[De divina proportione via wikimedia]

Another classic SP feedback technique is offering your comments in this format: "When you did X, I felt Y." For example: "When you moved my arm out of your way without saying anything, I felt vulnerable and helpless."

This is the only SP technique I've ever attended a (brief) training on. I know a lot of people hate it because it seems forced and routinized. I resisted it at the beginning, too. But with practice, it's become very natural to me, and now I find it to be one of my most important feedback tools. Here's why:

• I value it for the way it really forces me to truly examine what I felt and why I felt it. It's an excellent tool for self-awareness. The more I know about what makes me comfortable or anxious, the better feedback I can give students.

• Because it focuses on my emotions and observable behavior, rather than the student's motive, it's much harder for a student to argue or dismiss my feedback. This reason alone makes it worth becoming comfortable with the X/Y technique. It keeps the discussion patient-centered.

• I love how it expands my range of expression and allows for more nuanced feedback. Otherwise a lot of feedback is often binary: either good or bad.

• It works for positive and negative feedback equally well. When I tell a student something s/he did made me feel safe and supported, I can visibly see the relief on the student's face. A concrete expression of something that worked well for a patient is as valuable as a comment about something that could be improved.

• It's individual to the SP: different SPs often interpret the same behavior different ways, but express it the same way: "I liked it" or "I didn't like it." Using the X/Y format gives students more information about how their actions are being perceived, which makes the full range of patient reactions more visible.

Though I didn't learn it this way, I also often add: "If you had done A, I would have felt B" like so: "If you had asked me to move my arm, I would have felt like I had some control in a vulnerable situation." This gives students a concrete way to adjust their behavior in response, which I think is critical for good feedback.

However, it can be easy to slip into blame or projection, twisting the format into "When you did X, I felt you were being Y." For instance: "When you asked me the same question again, I felt you weren't listening to me." Assigning motive to a student often leads to a more defensive reaction. Better: "When you asked me the same question again, I felt unheard." When I want to comment on motive, I find it more effective to ask about it directly: "Why did you ask me the same question again?" After the student answers, I can almost always use the agreement technique to redirect and align our goals together without defensiveness.

Homework:
To help me practice this technique in the beginning, I created my own list of Y emotions. I also added a Z category when I needed to shape the conversation around my general values as a patient. I don't use it much anymore, but whenever I work at a new school/event I review it since something unexpected is likely to come up.

Extra credit:
Discovering the concept of non-violent communication a couple of years ago really went a long way towards helping develop the X/Y feedback skill and giving better feedback in general. I really like how it centers itself around empathy. I'm not 100% sold on the whole system, but as a feedback lens I have found it to be very useful.

Case preparation

An SP prepares for a case.
[study for The Apotheosis of Homer via wikimedia]

Since I work for so many different schools, I've had to develop a case preparation method that is able handle as many different cases styles and expectations as possible.

Cases are often written poorly, with important information scattered or repeated in slightly different ways. Sometimes a case seems clear until a student begins asking questions, at which point you realize you're missing a key piece of information.

So here's how I analyze a case to prepare for an event at any event that follows an OSCE-like model:

• Apply heuristics: In the same way students memorize chunks of questions in order to routinize the asking of them, so do I. So regardless of how the case is written, I review it by looking at the elements categorically. Do I know the answers to the most common HPI questions? Do I know the answers to the basic questions for the patient's history, like... PMH: meds, allergies, surgeries, hospitalizations; FMH: parents, siblings, grandparents; SHx: tobacco, drugs, alcohol, diet, exercise, occupation, living situation. Because none of the schools I work with teach us these heuristics, it took me several years to be able to recognize the categorical details underlying most cases.

• Organize top to bottom: Often symptoms are not written in any particular order that I can see. This is made especially difficult if I need to track symptoms the character doesn't actually have but that students need to ask about for credit. So to help me memorize them, I re-organize them in order from top to bottom. Things like fever, dizziness, and headaches are at the top of the list, things like leg edema are at the bottom. Sometimes I may even draw a little person with appropriate markings to help me visualize the symptoms. I also do this for the PE.

• Create kinetic cues: When re-organizing symptoms, I will also create a gesture for each item. It's pretty easy to forget whether a student has asked about a particular symptom during a long encounter, or after several encounters. Performing a gesture at the same time as I answer the question helps me retain it longer. For instance, if a student asks if I have had a headache, regardless of the answer I may touch my temple. If the gesture is natural enough, the student won't notice it at all. If it's less natural, I may wait until the student is looking down at the clipboard. 

• Create a timeline: This is especially important for cases with a lot of past medical history or social history. It's so helpful to see the progression of things in a clear, logical order.

• Create acronyms: for schools that have social checklist items I tend to forget to watch for during the encounter, I create an acronym to review with myself periodically during the encounter. For instance, sometimes I forget to mentally check if the introduction is complete. So if I am at a school that wants me to track the introduction, empathy, rapport and whether the student used my name, the acronym might be ERIN (Empathy Rapport Intro Name).

• Rewrite: I frequently rewrite cases in ways that make more sense to me. For instance, I may rewrite a case using only positive findings, rather than trying to remember which findings are positive and which ones are negative. I frequently rewrite a case using only the heuristics and use that as my main case review. I may rewrite a case listing differences & similarities between characters if I am doing similar cases at different schools.

Discussion question:
What tricks do you have for preparing, organizing or memorizing a case?