Calliope, the muse of epic poetry, approves this post.
[La Muse Calliope via wikimedia]

This post original began as simply a grateful reference to Empathy 101 (how to sound like you give a damn), because I give similar feedback to learners. I nodded deeply in agreement when I read:

• "Reassurance often fails if the physician does not also communicate an awareness of the patient’s deepest fears or concerns." 
• "This model of doctor-patient communication begins with empathic listening and responding, requires reflectivity and self-understanding, and is in itself a healing act."
• The list of "Statements That Facilitate Empathy," which is a particularly useful tool.

But then I realized these quotes and tools are all by the same person, which is how I discovered Dr. Jack Coulehan. Coulehan has written both "Let Me See If I Have This Right… – Words That Help Build Empathy" for the Annals of  Internal Medicine as well as the textbook Metaphor and Medicine: Narrative In Clinical Practice.

Sadly, neither of those references appear to be available via my normal channels, but some of his other books are, and that's how I learned Coulehan is both a doctor and a poet!

For instance, in addition to his own poetry, Coulehan edited Chekhov's Doctors: A Collection of Chekohov's Medical Tales as part of the Literature and Medicine series. Perfect for actors, eh? The Kindle edition has a much more interesting description of it: "In his brief but distinguished life, Anton Chekhov was a doctor, a documentary essayist, an admired dramatist, and a humanitarian. He remains a nineteenth-century Russian literary giant whose prose continues to offer moral insight and to resonate with readers across the world. Chekhov experienced no conflict between art and science or art and medicine. He believed that knowledge of one complemented the other. Chekhov brought medical knowledge and sensitivity to his creative writing—he had an intimate knowledge of the world of medicine and the skills of doctoring, and he utilized this information in his approach to his characters. His sensibility as a medical insider gave special poignancy to his physician characters. The doctors in his engaging tales demonstrate a wide spectrum of behavior, personality, and character. At their best, they demonstrate courage, altruism, and tenderness, qualities that lie at the heart of good medical practice. At their worst, they display insensitivity and incompetency. The stories in Chekhov's Doctors are powerful portraits of doctors in their everyday lives, struggling with their own personal problems as well as trying to serve their patients. The fifth volume in the acclaimed Literature and Medicine Series, Chekhov's Doctors will serve as a rich text for professional health care educators as well as for general readers."

The intersection of art & science is one of my very favorite things. Looking forward to reading more work by Jack Coulehan.

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.

The gendering of imaginary medical professionals

Because women are always nurses, right?
[Train to be a Nurse via wikimedia]

As an actor and a conscientious person, I am interested in our habitual language choices, especially relating to intrinsic human qualities like sex, gender, race, etc.

For instance, there are times during an encounter when a student may refer to my PCP or someone treating me for a particular condition in the case. And almost invariably, the gender of this doctor who doesn't even exist is male. This is true even if the student asking is a woman.

student: "Have you seen a doctor for this condition?"
SP: "Oh, yes."
student: "What did he tell you was going on?"

So I am surprised when, even after all these years, I fall into the same trap:

student: "When did you last see your doctor?"
SP: "I saw him last month."

When I use a masculine pronoun by default, I have to let it go because I don't want to do anything to derail the scenario. But I mentally wince when I hear myself say it.

However, if the student defaults to a masculine pronoun, I can choose to ignore it or challenge it, depending on what feels best for that interaction. For example:

student: "Have you seen a doctor for this condition?"
SP: "Oh, yes."
student: "What did he tell you was going on?"
SP: "She told me to come back for more tests next month."

As an SP, I find I don't even need to add emphasis to "she" or act offended in any way. Just changing the pronoun is enough to change the dynamic and get the student's attention.

It takes a lot of concentration to flip the model and not just go along with it, especially when I'm concentrating on the rest of the encounter requirements, which is why I don't remember to do this as often as I would like. But when I do I feel like I'm helping to create the kind of world I want to live in.

Bonus points:
Other gendered professions in scenarios (a living list): apparently social workers are female, too.

Extra credit:
If a student-doctor uses the term "lady doctor," please call them out on it either in character during the scenario or gently during feedback. (Yes! I've heard it!)

Setting the Standard:
Women can be doctors, too. In fact, nationwide almost 50% of students in medical school are women. I recommend using a feminine pronoun for all imaginary medical professionals to reinforce that possibility and offset the default gendering of medical professionals.

Acting like the moon

After a particularly moving SP performance.
[One Hundred Aspects of the Moon via wikimedia]

Sometimes a student or an observing faculty member will thank me after a scenario, saying "You're a really good actor!" And I appreciate that. It's flattering and reassuring that they think I've done a good job.

But I also think of a Japanese folktale comparing two actors playing the moon. After the first actor performs, the audience praises him: "You shone so beautifully! So bright! So magnificent in the sky!" The second actor, however, performs so naturally he was barely noticed.

Which actor was better?

Pain scales

Ideally, when I am portraying a patient in pain, my portrayal will give student doctors a clue as to how much pain I am in. But students are also trained to ask the classic question: "Can you rate your pain for me?"

Classic universal pain scale via nshealth.ca.
[click to embiggen]

Above is the classic pain scale. However, instead of saying "zero being no pain and 10 being the worst pain possible" students often say, "where 0 is no pain at all and 10 is the worst pain you've ever felt." I always think this is a little limiting, because the scale could change for each patient depending on how much pain a patient has experienced in a lifetime. For instance, a patient who has given birth may rate an ankle sprain at a 6, whereas someone who has sprained an ankle may rate it a 10 if nothing else worse has happened to them. Cases are written so that all patients give the same rating, but when the question is asked this way, as an SP I always have to think about it: what is the worst pain I've ever felt? (Pulmonary embolism, in case you're wondering.)

Sometimes, student doctors will simply ask "Can you rate your pain on a scale of 1-10" and I have learned to ask "Is 10 bad or is 10 good?" to remind them they haven't given the patient a complete scale. Because outside of the simulation, if a doctor doesn't clarify, the patient may give what s/he considered to be a reasonable guess, and the doctor may get incorrect information.

Badly written cases will often only have one pain rating attached even though the pain has changed over time. So if  student doctors ask questions like "What did the pain start at?" or "How long has it been at a 4?" as an SP I always wince and guess. The rule of responding to cases that don't have a definitive answer to a student question is that the answer is either "no," "I don't know," or that the answer won't affect the case. But I certainly feel like a better SP and more standardized when I know the answers to good questions.

I say our affect should be an indicator to the patient's pain level, but only one school I work with attempts to standardize SPs to portray pain based on the case rating -- and then usually only for the really important cases that could affect a student continuing with the program. This can make it more difficult for student doctors to interpret my pain, because other SPs may portray a 6 less seriously than I do. Some students may feel I am "overacting" if I portray a 6 with a "wrinkled nose, raised upper lip, rapid breathing," even though that's the official pain scale.

However, my favorite pain scale is from Hyperbole and a Half:

0:  Hi.  I am not experiencing any pain at all.  I don't know why I'm even here.
1:  I am completely unsure whether I am experiencing pain or itching or maybe I just have a bad taste in my mouth.
2:  I probably just need a Band Aid.
3:  This is distressing.  I don't want this to be happening to me at all.
4:  My pain is not fucking around.
5:  Why is this happening to me??
6:  Ow.  Okay, my pain is super legit now.

7:  I see Jesus coming for me and I'm scared.
8:  I am experiencing a disturbing amount of pain.  I might actually be dying.  Please help.
9:  I am almost definitely dying.
10:  I am actively being mauled by a bear.
11: Blood is going to explode out of my face at any moment.
Too Serious For Numbers:  You probably have ebola.  It appears that you may also be suffering from Stigmata and/or pinkeye.

This scale is the one that most closely matches how I actually feel about pain in my own life. Honestly, if I rate something as a 9, I want the doctor to know I feel I am almost definitely dying. Few people go to the doctor unless the pain is at least a 3 or more. So even though a 3 is considered "mild" pain in the classic scale, it's significant enough to drive the patient to see a doctor. In other words, the pain is bad enough for someone to miss work and/or pay a lot of money to address it. At that point, no pain is "mild" pain, in my opinion. As a patient, one of my biggest fears is that the doctor won't take my pain seriously. I worry they may think a 6 is mild, even though, as the Better Pain Chart shows, I feel like "my pain is super legit now."

Sometimes, students describe the pain scale "where 0 is no pain at all and 10 is the worst pain imaginable." When they do, I smile to myself and think of this xkcd comic:

[click to embiggen]

I can imagine a LOT of pain. Cases always have pain ratings attached to them that won't fluctuate based on how students ask this question, but when the scale is described to me this way I think, if I were a real patient, I would drastically revise my estimate downward.

Extra credit!
If students ask about the ADL scale right after the pain scale, it can be very confusing for patients because the scale is reversed. When that happens, I think it's better to ask about it as a percentage than a single number.

Further reading:
McSweeny's has a delightful article about SPs being trained to simulate pain. Wish more schools did this!

Postscript (Jun01.2020): 

When the coronavirus devastated the profession, this pain scale felt especially appropriate:

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.