It takes more than empathy to truly understand.
[Harmonie der Geschöpfe via wikimedia]

My first post on Setting the Standard began: "If I could teach medical students only one thing as an SP, it would be to provide empathy first." I'm a big proponent of empathy as a way to reduce the power differential and enhance connection & communication between doctors and patients.

So after I posted "Empathy is the highest form of respect," a friend sent a link titled "Empathy Won’t Save Us In the Fight Against Oppression." I was intrigued. I became even more intrigued when that article referenced "The Baby and The Well: The Case Against Empathy."

In it, Paul Bloom argues, "Empathy has some unfortunate features—it is parochial, narrow-minded, and innumerate. We’re often at our best when we’re smart enough not to rely on it."

Recognizing the limitations of empathy helps me give better feedback to learners. I still believe empathy should be a starting point for patient encounters. But empathy alone is not enough, which is why I also pay close attention to the other values in my feedback hierarchy like respect & autonomy.

In scenarios, a major limitation of empathy is a lack of imagination from the person using it. Frequently, empathy is employed in a fashion similar to the Golden Rule: How would I feel in that situation? But empathy should be more complex and nuanced than that. SP scenarios are a good way to increase learners' exposure to a wider variety of situations than they might otherwise find themselves. But there are situations and lives it is almost impossible for us to truly understand if we haven't lived them. This is especially true for vulnerable & marginalized patient populations.

So when empathy fails, respect and unconditional positive regard can fill the gap. Bloom writes, “Our best hope for the future [lies] in an appreciation of the fact that, even if we don’t empathize with distant strangers, their lives have the same value as the lives of those we love.” That's always good feedback to give learners.

Actor Seeks Role

All I can think of when I watch the SP-inspired "Actor Seeks Role" is how ironic it is that we work in the health industry but have so little access to health care:

This short film is much funnier and more tragic than when I wrote: "SP encounters are not a substitute for medical care." It's so easy to forget that SPs are considered temporary workers at best, and not eligible for the kinds of benefits other employees receive. Only one school I work with allows SPs to access medical care at their institution (which is, quite honestly, a big reason why SPs work at that school).

The Affordable Care Act really made a big difference in my ability to continue to contribute as an SP without living in constant fear of debilitating medical bills. I sure would like it better if schools were willing to include us on their health plans, though, or access to their care at a reduced rate.

Extra credit:
Of course, it's also charming to see how another SP studies, performs, and grapples with how to be a serious actor while being paid to be a pretend patient. Even while obviously exaggerated, it's certainly more realistic than that Seinfeld episode.

The point of greatest vulnerability

A learner carefully prepares to hear feedback.
[The Goose Girl via wikimedia]

I've written about the value of student self-reflection before. My goal for feedback is to finely tune it for this encounter for this learner, and so I usually begin with the standard open-ended question "How did that go for you, [name]?". Since I always have a ton of potential feedback but a very limited amount of time, I begin this way in part because I value knowing what direction the student wants to go, as I wrote below:

"For me, this is the most important part of using self-reflection: be genuinely interested in the student's response. When I ask, "How did that go for you?" I am not waiting for a perfunctory answer so that I can launch into my own feedback. I am waiting to see where (or if) our needs overlap."

This method and focus developed intuitively over many years, so when I heard Valerie Fulmer say this recently, I felt something click sharply into place along with a deep sense of validation:

"The first thing a student says [when feedback begins] is the point of greatest vulnerability."

Yes! "The point of greatest vulnerability" really helped crystallize why I approach feedback in this way. Now that I know this explicitly I can be even more strategic about how I respond to the student's response, including how I employ agreement in feedback. Also, maintaining "vulnerability" as a keyword helps me remain in a state of compassion during feedback, even if faced with a difficult encounter or student.

Bonus points (added 08.28.2015):
I just had to remind myself of this recently, in fact: a learner came into my room for feedback and before I said anything immediately exclaimed: "That was SO AWKWARD!" We laughed briefly and I was about to "begin" my feedback with the standard "So how did that go for you?" when I realized she had already told me how that went for her: awkwardly. That was her point of greatest vulnerability. So I began my feedback by saying "So what made that awkward for you?" instead and we had a great conversation.

There's an app for that

A patient completing a student feedback survey.
[Portrait of Nicholas Thérèse Benôit Frochot via wikimedia]

Medical students at the University of Pittsburgh are developing a patient feedback app: "The app allows both patients and students to rate how they think an appointment went. Patients also can give feedback on how the student performed."

Honest feedback from patients is a noble goal. I would love to contribute to a system where patients felt they could offer honest feedback and know they had been heard.

Some issues I see:

• Data without plans for followup, development, training and/or mentorship is useless. Don't bother collecting data until you have plans to do something with it. (I feel this way about SP checklists, too.)

• It's very difficult for a patient, who has a huge emotional investment in the experience and the outcome, to step back and offer kind, trustworthy, respectful feedback to learners. Even SPs often have trouble doing this, and we're only pretending to have the experience!

• Patients can be expected to ignore the parts of the feedback they don't care much about to focus on the thing that really bothered them. That makes the data less useful. (This is true for SPs, too.)

• When is the survey administered? Feedback about any encounter should happen as soon after an encounter as possible, so that both parties remember the details. If the patient is asked to do it at home, after the encounter and after the patient has seen several other medical professionals, the patient is going to give less reliable feedback.

• If the app is something a patient is expected to download and use on their own phones, that will further reduce the usefulness of the survey. Plus, a smartphone app only reaches those who can afford smartphones. I hope the system can be adapted so those who don't use smartphones can still have a say.

Also: "Students already get feedback from what are called standardized patients — actors who are assigned a specific situation and medical illness. But according to Patel, that feedback is mostly objective: Did they wash their hands and avoid medical jargon? Students are often left with a lot of unanswered questions."

That may be true at the University of Pittsburgh, but it's not true everywhere. In fact, I would say that limiting SPs to objective feedback limits the full potential of SPs. However, the subjective feedback must be very capable to be effective. To do it well, SP must be trained to articulate their experiences in ways patients cannot (due to things like the power differential as well as a general lack of constructive feedback training or emotional analysis).

Also, more SP encounters could help. Many schools only offer end-of-the year testing. In high-stakes exams most students are focused on the outcomes, not the feedback. The advantage of the app is that students would ideally be receiving a consistent stream of feedback throughout their clinical experiences, which gives them more opportunities to notice patterns and make changes. Imagine what could happen if students saw more SPs over the course of a year!