An SP resists a command.
[Tor's Fight with the Giants via wikimedia]

During feedback, the learner was quite upset I didn't follow his instructions during the scenario. When faced with a highly charged situation, de-escalation techniques are essential before asking for compliance, or I will feel all of this all at once:

I want my phone. I want to find the papers. I want my mom to tell me everything is going to be OK. I want my boyfriend to die because if he doesn't he is going to kill me. I want to get rid of this blood and the smell. I want someone to tell me what is going on. I want to help. I want to die. I want someone to call me by my name. I want to know what is going to happen next. I want to scream. I want to disappear. I want to fight. I want someone to understand. 

I need to move. I don't want another person yelling at me. I don't want another man pushing me around, telling me to sit down. I can't hear with the blood roaring in my ears. I can't answer these questions. I feel sick. I don't want Ryan to die. I wish I hadn't come home. I wish I had never gotten involved with him. I don't know how I got here, why I took it for so long, how I had the strength in me to finally hit him back. I can't even imagine the life I should have been living if I had never met him but I want it so bad right now I can taste it behind my teeth.  

Am I a bad person because I hit him, or because I let him hit me? Either way, I'm going to be punished. 

Making a decision

"What do you think I should do?"
[Question to the Card via wikimedia]

Too many choices makes me feel overwhelmed. As a patient, when I ask a student doctor "What do you think I should do?" there are two good options:

1. Tell me what you think I should do based on your best understanding of my needs and yours. This will make me feel as if my request was heard and I can use this information as input into the decision I will eventually need to make. 

2. Ask me more questions to help me differentiate between the options so I can more clearly choose the right one for me. This will keep me engaged in the conversation and will give me confidence and clarity when I finally make my decision.

But sometimes learners who are really trying to maintain a patient-focused interview will say something like: "Well, I can't decide for you. Only you can do that. Everyone is different." And then stop.

The intent is good, but a statement like this should be the beginning of change talk, not the end! If the conversation ends here, I will feel unsupported, guilty for asking, and less confident in the student doctor. I will likely delay the decision until meeting with members of my support network, or I will defer the decision indefinitely. So use this phrase only as a preface before moving onto one of the other two options.

Homework assignment:
How do informed consent and the power differential contribute to this dynamic? Please write your answers in the space provided below. ;)

Tell me about yourself

I don't think you're going to like the answer.
[The Enchantress via wikimedia]

Sometimes innocent questions can come with a lot of built-in assumptions. That's why it's so important to establish trust and safety first. If a patient has a hard time answering what you think should be an easy question, there's probably a good reason.

"Tell me about yourself," they say as we begin. 

"Tell me about yourself," they say, and lean forward in their chairs, smiling. 

"Tell me about yourself," they say, as if we could have anything in common.

"Tell me about yourself," they say, not hearing the cracking of the earth, not seeing the way the light has been suddenly swallowed by the deep canyon that appears between us. 

"I don't know. What do you want to know?" I say, stalling for time, feeling my heart pound, feeling distant and alone, not knowing when they'll be ready to hear that my alcoholic father beat me and kicked me out of the house in high school. Not wanting to remember the first time I traded heroin for sex. Wishing I didn't have be on guard every second of every day and especially here when I just came in to fix my headache and I have no idea where my doctor is or who they are or what they're doing here and how long I have before they show pity or disgust, both of which will destroy me. 

"Oh, tell me anything." 

Like, how I sleep on the streets at night? How much I drink? How I almost went to prison for stealing a car one night? How every cell in my body felt like it was vomiting for three months straight when I tried to come clean two years ago? How I still miss my 9th grade girlfriend who was sweet and clean? How I feel I'm living on borrowed time since I turned 30 and I dream of making something good in the world that people will like, even if it's just cookies in a bakery? 

"I don't know. I'm pretty boring I guess."