An elderly patient patiently waits for her appointment.
[Portrait of an Old Woman via wikimedia]

Some people still say you can't practice empathy, that people either have this as a skill or they don't.  I disagree, which is why I like these elderly simulations in Poland:

Medical student Ludwika Wodyk fumbles her way slowly down the stairs, her movements encumbered by heavy strapping around her limbs and body, her vision distorted by special goggles. She is one of a group of medical students in Poland being given the chance to experience first-hand how it can feel to be an aging patient.

Empathy is something that can be taught, or at the very least, experienced. For many people, empathy is highly contextual, so direct experience with a problem can often give them insight into the barriers or complications of a particular population. This brings benefits like understanding, tolerance, and more creative problem-solving when the same circumstances arise again.

Elderly simulations can also be found in Britain and at MIT.

Extra credit:
When I roleplay older patients, I usually focus on the visual aspects. In future scenarios I want to pay more attention to the physical aspects and give feedback from the perspective of a person who might also have mobility, sight and hearing challenges as well.

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?

Quote of the Day

[Portrait of Robert Louis Stevenson via wikimedia]

"Our business in life is not to succeed, 
but to continue to fail in good spirits."

Robert Louis Stevenson

This was obviously not written about the concept of SP work, but it could have been. On the best of days, our job is to allow students to fail in good spirits. That's where the learning happens.

Alphabet soup

Embellishing a standard student mnemonic.
[16th Century Ornamental Alphabet via wikimedia]

One of the essential mnemonics for medical students asking about HPI is LMNOPQRST:

L: Location (where is the pain exactly? Can you point to it?)
M: Mechanism (how did this pain occur, if known? -- for instance, with trauma)
N: New (prior history of this pain or similar?)
O: Onset (when did this pain occur?)
P: Palliative/Provocative (what makes the pain better or worse? Not asked as a stacked question, hopefully!)
Q: Quality (describe the pain)
R: Radiation (does the pain move?)
S: Severity (how bad is the pain? often rated on a 1-10 pain scale)
T: Timing (how does the pain change over time? e.g. duration, contant/intermittent, sudden/gradual)

So brilliant! Because the alphabet is strongly ingrained in anyone who speaks fluent English, it's actually difficult to forget this one. The questions don't neccessarily need to be asked in this order during the interview, but if a student hits all of these points, the student has done a thorough job of asking the right questions to understand the patient's chief complaint.

Using the core value of "Empathy first", I propose a new mnemonic:

K: Kindness (empathetic statement, validation or reassurance)
L: Location
M: Mechanism
N: New
O: Onset
P: Palliative/Provocative
Q: Quality
R: Radiation
S: Severity
T: Timing

I love that including Kindness in the traditional HPI mnemonic creates a logical sequential addition and places empathy as the first element.

Extra credit:
I also use this mnemonic when memorizing my cases and checklists to verify I have all the info I need to answer a student's questions, even if that information isn't in the case. In which case, I also add:

U: Unusual/associated symptoms
V: actiVities of daily liVing (aka ADL: how does this affect your life/work?)
W: What do you hope to get out of this visit?

Bonus points:
An advanced student will begin a patient encounter with an open-ended question like, "So tell me what brings you in today." After they allow me to tell my story in my own words, the advanced student will then go back and ask the alphabet questions I didn't talk about to fill in the blanks naturally. This enhances rapport with the patient, speeds the interview process, and makes the student-doctor look gracious and competent.

Quote of the day

[Portrait of Pablo Picasso via wikimedia]

"Art is a lie which makes us realize the truth."

Pablo Picasso

Now replace "Art" with "A scenario." Discuss.

Different event styles

SP events can be as varied as saris.
[Styles of Sari via wikimedia]

Different schools offer different styles of events to their students. Though they come in many flavors, one way to classify them is whether the encounters are graded and observed.

Ungraded, unobserved: usually informal sessions commonly used for students to practice physical skills with each other. They can also be optional sessions with SPs used as prep for the bigger tests. 

Ungraded, observed: informal sessions with several observers. One example of this is small group encounters, which are frequently stopped/started and discussed in order to practice or re-do specific aspects of the encounter. Another common form of this is the Objective Structured Clinical Assessment (OSCA), an ungraded session which frequently includes an observer in the room filling out a form during the encounter. But since the encounter doesn't affect the student's grade, the atmosphere is more informal. Sometimes these are practice for OSCE preparation, below. 

Graded, unobserved: this is an uncommon form usually available at places with a limited SP program. The SP is alone with the student in the scenario and evaluates the student without oversight. 

Graded, observed: The most common form of this is the Objective Structured Clinical Exam (OSCE). These are typically not observed in the exam room. Instead, faculty may observe from a video-enabled observation room. Since these are such high-stakes exams, the encounters are also frequently recorded in case of dispute. Within graded scenarios, there are at least three levels of intensity: those that affect part of the overall class grade, those that affect whether the student continues in the program, and remediation exams if the students fails the first time. (Remediation exams are intense.)

Extra credit:
I much prefer to work with schools that offer regular scenario practice along with higher-stakes events. However, many schools I work with only offer scenarios as part of an evaluation (usually at the end of the term), which makes them much more stressful for students, and therefore much more stressful for SPs. I hope this changes over time.

Discussion question:
What scenario formats does your school use?

Role reversal

Who is the student and who is the master?
[A Teacher and his Pupil via wikimedia]

Adam Bitterman proposes a "reverse" SP scenario where actors pretend to be doctors and students pretend to be patients as a way to enhance student empathy and etiquette. How fun would that be? I would start by creating five encounters with different types of doctors and a very simple history for students, so that the student experiences the way different doctors can affect the same patient with the same case.

I can imagine many ways it could be enlightening. I also see some ways that medical students would still have trouble empathizing with the experience of most patients. For instance, technical jargon wouldn't make students feel stupid. Students would still likely anticipate the exams being performed, and so never experience the frustration of unclear instructions. Students are unlikely to feel as nervous or ashamed of their bodies as patients do when being exposed or asked personal questions.

Still, it seems like a worthwhile experiment to reinforce good habits, especially paired with some self-analysis exercises. In what ways do the students resemble or respect the Standardized Doctor in the scenario? What did the SD do that caused them to be uncomfortable? I would love to see a checklist of SD communication skills that the student "patients" fill out.