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. 

Computer simulations vs SPs

Choose your own adventure!
[La Vérendrye via wikimedia]

I don't know whether to be excited about or skeptical of SIMmersion. A little from Column A, a little from Column B, I guess.

I love technology. I love giving students more chances to practice difficult conversations. As an additional tool in the toolbox, this looks stellar. I can totally see learners using this to practice before an SP encounter.

But then I read things in their press release like:

"A computer screen might not be better for teaching the physical examination of a human, but interacting with a well-designed system is better for teaching students how to talk with a patient [than interacting with SPs]."

If they truly feel this way, and if this is the way they are marketing the product, then the whole foundation is suspect.

I actually went through their sample Motivational Interviewing scenario. Engaging with a computer is fun, and including the MI curriculum as a preview before and as a guide during the encounter is very effective.

But the timing and emotional range is all wrong. Learners, especially beginning ones, struggle with a number of things that can adversely affect patient interactions, like word choices and nonverbal cues. This is especially true in the context of a fast-paced encounter. It's much easier to pick the right statement when you have a limited number of options and as much time as you want to think about it.

Also, there is no verbal feedback in SIMmersions. I strongly believe immediate feedback/debrief with an experienced facilitator featuring student self-reflection is an incredibly effective component of learning. Instead, SIMmersions features a woman in the bottom corner of the screen who responds with appropriate body language based on your response, and offers suggestions for the most effective thing to say next.

I see the usefulness of SIMmersion primarily as an early part of skill acquisition. In my ideal curriculum, learners would develop a new skill like this: beginning with a lecture/introduction, then independent reading/videos, then observation, then SIMmersions, then group work, then SP work with timeouts and a facilitator, then a solo SP.

However, this whole things makes me think we're not far off from The Diamond Age's prediction of "ractors," who are essentially crowd-sourced, on-demand scenario actors able to perform anywhere. Wouldn't that be fun?

Delivering a diagnosis

A learner explains a diagnosis to an SP.
[Girolamo Mercuriali via wikimedia]

When learners try to give me a diagnosis, I often feel unsatisfied because the explanation is missing one or more key components that will help my understanding.

When I go to the doctor I want to know these things in this order:

• How has this conclusion been reached? Without a summary of findings or history, I have less ability to relate the diagnosis to my chief complaint. Transparency allows me to trust the diagnosis when it comes.

• What is it? The diagnosis should include the medical term and the layman term if there is one. For instance, if the diagnosis is "Non-Hodgkins Disease" or a "lymphoma," I may not understand the learner is telling me I have cancer. If it is a serious diagnosis, I ask learners to leave a beat at this point so I have a chance to process it before continuing with the other parts.

• What does the patient know about it? After the diagnosis has been named and I know how the doctor has reached that conclusion, it is very effective if the student-doctor opens up the conversation with, "What do you know about [X]?" This allows the patient to lead the conversation and it gives the opportunity for the student-doctor to clear up any misunderstandings or praise the patient for their knowledge.

• How serious is it? Regardless of the diagnosis, there is always a range of outcomes and consequences. I will likely leap to the worst-case scenario unless I know what the range is. My perception may also change based on any previous experiences I've had (directly or indirectly) with the diagnosis. If I'm not going to die immediately, hearing, "X% of people with this diagnosis have Y happen to them" is really helpful. This is especially true if I am hearing the results of a screening test as opposed to a true diagnosis. 

• How long will this affect me? Knowing whether the diagnosis will affect me for three days or three years shapes my ability to understand the scope and impact of the diagnosis. Sometimes learners tell me they will "treat" my condition for a period of time: when I hear this, as a patient I think they mean they will cure it. So I want learners to be clear whether this is a treatment meant to prolong my life, or whether my condition is something that will resolve after treatment.

• What's the next step? And equally importantly, what's my next step? Even if my next step is "wait until the test results come back in 2-3 days," I still know what to do.

Plain language, reassurance, validation, empathy, teach back, collaboration, etc. are good tools to use within this framework, too, but they can't be used to replace one of these steps.

For example:

"Based on your coughing & fever, and those sounds I heard in your lungs, I think you probably have pneumonia, which is a lung infection that causes fluid to build up in your lungs. You're young and healthy so I'm not too concerned right now, but I'm glad you came in so we can treat it before it gets worse. Fortunately, it will probably get better in a couple of weeks after we begin treatment. I'm going to recommend a chest X-ray and a test of what you're coughing up so we know for sure it's pneumonia and so we know what kinds of medications to give you. How does that sound?"

Learners are of course welcome to elaborate on these points if the patient indicates they want more information or clarity. Otherwise, each of these steps should be no more than 1-2 sentences each.

When learners cry

"When doves cry..."
[L'enfant à la colombe via wikimedia]

Only a handful of students have cried while working with me, but they have all been memorable. But I don't take it personally, because they always happen during high-stress scenarios, like when the event is required to pass or when my character has been terrifying. Sometimes the learner is suffering from something happening in their life which magnifies any bump in our encounter into an insurmountable challenge.

Usually these encounters are unsatisfying, but the learner generally holds it together during the scenario. When feedback begins, though, so do the tears. In those situations, I've learned that feedback about the encounter in those cases is almost entirely wasted. What is more helpful is to explore what triggered the student and what's going on for them. Empathy first works for learners, too! If there's time, I may also give feedback about compartmentalization, stress management and how to manage negative thoughts.

In general, feedback should role model the kind of interaction you want with providers. So if I stay with my traditional feedback agenda in those cases, I am training learners to stick to their agendas despite the emotional and nonverbal cues a patient is exhibiting.