[The assumption of Mary via wikimedia]

"Empathy is the highest form of respect."

Lisa B. Marshall

I have yet to write a separate post about evaluating respect, but in the Feedback Hierachy post I wrote:

"Respect indicates an awareness of the patient as an individual worthy of consideration and dignity. For instance, respect includes things like validation, normalization, accommodation, reflective language and transparency. Respectful student doctors are non-judgmental, honest, don't interrupt, admit uncertainty, apologize when necessary, take responsibility, keep commitments, and don't make assumptions based on class, gender, sexuality or race."

But since empathy is one of my core values, I find Lisa B. Marshall's quote fascinating. What do you think?

Uptalk?

I'm not sure? If this is serious?
[Sibilla via wikimedia]

"Did the student seem confident?" is one of those subjective questions SPs are often asked to answer on checklists. So when student-doctors frequently end their sentences as if they are questions?  I often advise learners to limit their use of "uptalk" during feedback.

As a patient, excessive uptalk causes me to lose confidence in the student-doctor because it can come across as if s/he is uncertain or seeking validation. This is especially true if the uptalk is paired with other signs of deference, like cocking his/her head to one side.

Nonverbal cues strongly affect patient trust & confidence. Learners often expressive gratitude when given feedback about things like tone & posture because they are often invisible things learners can change which have real impacts on patients.

Uptalk can be controversial, however. I recognize it is often gendered: I give women this feedback more than men, and women are more often socialized with habits that undermine their authority. But learning to project respectful authority & appropriate confidence are keys to navigating the power differential between doctors and patients. So when I give feedback to learners about uptalk, I try to keep it as neutral as possible. Sometimes we replay and reframe sentences that stood out during the encounter. I don't expect to change a lifetime of vocal inflection in one session, but awareness is always the first step.

Do you have heart disease?

Not for the faint of heart.
[Heart diagram from Grey's Anatomy via wikimedia]

The other day a medical professional was taking my medical history and asked, "Do you have heart disease?" And as I always do when a learner asks me that question during a scenario, I thought, What does that mean?

"Heart disease" is such a broad category, and patients rarely refer to their own experiences that way. Patients who have had heart attacks, high blood pressure or high cholesterol may not include those items when asked about "heart disease."

"Disease" is a big part of the problem here, too, I think. As a patient, I wouldn't think to include palpitations when asked this. Or a pulmonary embolism. Does a stroke count? What if I've been told I have HBP or high cholesterol but am not being actively treated for it?

It is especially important to be clear when asking a string of questions to which the answers are usually no. Because as a patient, it is much easier to say "no" than it is to stop the flow to ask a clarifying question.

Extra credit

The term "cardiovascular disease" is even worse. Plain language is important!

Setting the standard

If learners at your school ask broadly about "heart disease," train SPs how to respond realistically and in a standardized way, because otherwise they are almost certainly all giving different answers. Better yet, train learners to ask a broad question about health history first, then to follow up with specific examples based on chief complaint, case and/or presentation.

Maintaining the Mask

A glimpse of the SP under the patient mask.
[Self-portrait with Mask via wikimedia]

When learners feel particularly self-conscious in a scenario, they often break character. This could be because the scenario is new, they're not confident in their abilities, or because a subject is particularly uncomfortable (e.g.: sexual history).

When a learner breaks character, they may talk to themselves, ask the SP a direct question rather than the patient, or make a guess about what they think is supposed to happen in the scenario. It is often accompanied by an expression of appeal towards the SP to get the SP to break character, too. Sometimes they smile to indicate they're in on the joke. I think learners do this because it gives them some control & power in a situation where they feel insecure.

As an SP, it takes a tremendous amount of will to resist or deflect this. So if a learner asks me a direct question like, "So am I supposed to examine your heart?," I have to react like a patient: "I don't know? I guess? I mean, you're the doctor, ha ha!" Or I have to keep a straight face while the learner is clearly looking for more information but hasn't asked for it yet.

Sometimes that's enough pushback for the learner to realize they really do have to pretend to be a medical professional for this encounter. And so we move on.

Sometimes it's not, though. A scenario is a fascinating place that only works when everyone involved agrees to create a shared fantasy. If one person isn't into it, the whole thing limps along until time is called.

That can lead to awkward feedback. In a scenario like that, if I try to give feedback about what I observed, the learner is often defensive. So instead I try to talk with them about why the s/he had trouble taking the encounter seriously. Sometimes we talk about the purpose of scenarios. Even if it doesn't feel real to them, it feels real to me. So the more seriously they treat the encounter, the better feedback I can give.