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.

Turning it around

Feedback isn't always straightforward.
[A Turn in the Road via wikimedia]

I certainly enjoy a good SP encounter. I love discovering how effective behaviours manifest and how they affect me so I can incorporate them into future feedback.

But one of my very favorite things is when a poor encounter becomes an excellent feedback session. This is only possible in places that allow the SP to have a genuine conversation with the learner, rather than using a specific format or a written form. But when it works it makes both of us leave the encounter feeling better. I see how the learners' posture & expressions change and they leave knowing how to make it right, feeling hopeful instead of defeated.

For instance (this is a living list. Last updated May 23, 2017):

• When the learner returned for feedback, he immediately admitted it had been a terrible encounter. Together we analyzed why, then I guided him through creating a specific plan to enhance those skills before the next event.

• During feedback during a poor encounter a learner admitted he had just been going through the motions during lung auscultation, but when he realized it he forced himself to do the exam again paying closer attention. It didn't affect the findings or anything else about the encounter, but I was so impressed I praised him for his self-awareness and integrity. Even if he got nothing else out of that encounter, I felt that was worth the whole thing.

• I could tell the feedback for this unsatisfying encounter wasn't landing for the learner until I stepped laterally and asked her why/how she had gotten into this particularly specialized program. Hearing her answer allowed me to target my feedback to meet her needs and her entire attitude became engaged and curious.

• "Oh, I should ask more questions!" the learner suddenly exclaimed during feedback after a particularly confusing encounter. I wanted to hug him.

• How I learned to begin each encounter with student self-reflection.

• Once a learner who had an awkward encounter came back to feedback crying. I didn't even try to give her feedback: I got her tissues, a drink of water, and asked her what was going on in her life. We talked a bit about how to compartmentalize emotions and release them between patients so she would be ready to do the next OSCE encounter in the rotation.

• We had had a lackluster encounter: even though he was using the right words, I had considered the learner scripted and demanding. So I used the Feedback Hierarchy to talk to him about posture, tone, facial expressions and word choices to convey sincerity. During feedback he became much more animated and engaged. As he left he shook my hand: "Thank you! That was was the best feedback I have ever had. That's exactly what I've been looking for."

• After a difficult encounter with a resistant client, I asked the group what questions they had. Nobody said anything for a long moment, then one woman spoke up: "Why were you so mean?" she asked, only half joking. Everyone laughed nervously, and I was tempted to laugh it off, too. But instead, I said, “Great question! Why was I so mean? Let’s ask the group! What are some reasons why people might be mean in a situation like this?” The group talked about a lot of factors that make people uncooperative: hunger, illness, power/age differentials, independence, control, comprehension. The tone immediately flipped from rejection to empathy & inquiry, which persisted throughout the debriefing. I am certain they will feel more kindly towards this kind of client in the future.

• He was clipped, curt and offered me no empathy for my symptoms. I had a feeling I wasn't the only SP who had worked with him who felt this way, so after the traditional "How did that go for you?" I asked, "What patient interaction skills are you working on? What's something another SP has mentioned that you are trying to incorporate into patient encounters?" When he told me what it was, I was able to validate I had seen him try that and we were able to discuss how to communicate that skill more effectively. That gave me a chance to talk about what I had noticed and he was able to reflect back to me that he really heard it and how he could imagine how small it made me feel. By the end, he was telling me about why he had gotten into medicine, and my eyes were shining with compassion.

• Right from the very start, the learner constantly interrupted me. She would start with an open-ended question but then immediately close it or cut me off or finish my answer before I could even open my mouth! In feedback, when I asked her how it had gone, she said fine, but she felt like she didn't connect with me very well. What was the earliest moment she remembered not being able to connect with me? I asked. "Kind of right from the start," she said. I agreed with her and we walked through how she immediately closed her opening question, and then we examined several instances of other interruptions -- even during the feedback! By the time we were finished, she was astonished. "It's true! I do interrupt people! How could I not know this? I've done a lot of these simulations and nobody has ever told me that before!" She was almost elated at discovering this aspect about herself.

The case against empathy

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.

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!

Depression

This is exactly the expression I use when I am portraying depression.
[Sad News via wikimedia]

One of my favorite cases is depression. I know it sounds weird, but I love seeing how students handle it. Some are remarkably kind and empathetic, while some want to pass me over to a counselor as soon as humanly possible.

Regardless, here's feedback I often give learners dealing with a patient suffering from depression:

• Match the patient's energy: When a learner enters my room cheerfully and remains cheerful throughout the encounter despite my obviously uncheerful affect, I feel as if we are inhabiting two completely different realities. When the learner adjusts to more closely match my energy at the beginning of the encounter, I feel more understood and comfortable. However, as the authority, it's important the learner matches my emotional level without being pulled into it entirely. If the learner goes too far, I won't feel confident they will be able to pull us both out.

• Shape the conversation: Learners often want to jump into a depression screening as soon as they think I have depression. The traditional LMNOPQRSTU format doesn't always seem applicable because there is often no physical pain, but honestly, even with depression it's a good place to start because it helps me establish an HPI, which helps me feel heard. This also allows me to answer several easier questions to establish trust & safety with the learner before moving onto the more emotionally charged depression screening questions. Save the self-harm and suicide questions until the end (more on this below).

• Focus: Once a learner suspects depression, s/he usually wants to fix it. But it's impossible to fix depression in a 15-minute session. So I encourage learners to find better goals for the encounter. For instance, I think some good goals are to establish trust, assess my safety and get me to come back for another appointment. Anything else that gets handled is a bonus (within the confines of that case's learning goals, of course).

• Listen: I frequently tell learners during emotional and/or sensitive encounters, "Your job is to keep proving you are a safe person to talk to." So every active listening skill is critical to establish trust and safety: sincerity & other non-verbal cues, reflection, open-ended questions, validation, empathy, framing for sensitive questions, avoiding interruption & judgment, etc.

• Know when to keep things moving: Very occasionally I have a learner who is so empathetic and open to listening that we don't make any progress. As a patient, this can feel as if I've wasted my visit. So during feedback I talk with learners about how make progress while while remaining a trustworthy listener. This often involves setting achievable goals, a clear framework, collaboration, summarization, reflection, and the occasional kindly redirection.

• Showing the work: Even if it's completely obvious to the learner, depression may not be obvious to me, or may be associated with stigma I am unable to verbalize/recognize. Many patients do not come in for depression. They come in because they're tired or unable to concentrate, for example. So if the learner jumps to depression without explaining how it relates to my chief complaint(s), I will feel labeled instead of understood. If the learner asks questions or performs exams that don't seem related to my chief complaint(s) (like the mini mental status exam, for instance), it is likely to affect my trust in the learner and impair my motivation to return to this or any other medical professional.

• Asking about self-harm/suicide: I usually tell learners to leave this question until last because the answer could radically change everything and is the hardest question for me to answer. Plus, any question asked after this feels incredibly trivial. Everything a learner has done up up to this point to build trust, safety & rapport will allow me to feel more comfortable answering. How a learner asks this question is vital to ensuring a truthful answer, requiring appropriate framing & sincerity. I tell learners that changing their tone, posture, and eye contact are really helpful. Using my name helps focus me. 

If I admit to suicidal/self-harm thoughts, using validation & normalization can help convey acceptance and support: "Thank you for telling me that, [name]. It's very normal for someone going through what you're going through to have those thoughts. If you ever have thoughts like that from here on out, I want you to call [x]." Wait to assess my reaction. When it seems like I am ready to move on, without belaboring the point, offer hope by transitioning to the plan: "So, let's talk about how we get you feeling better."

If I deny those thoughts, then great! Validation & normalization are still useful to help transition to the plan and create a buffer in case I am lying: "I'm glad to hear that, [name]. Because it's very normal for someone going through what you're going through to have those thoughts. If you ever have thoughts like that I want you to call [x]." And then transition to the plan in the same way: "So, let's talk about how we get you feeling better."

• Identify and replace coping strategies first: if the learner remembers to ask about drugs/alcohol, and then recommends I take medications without addressing my alcohol usage, I cringe inside as an SP. But worse, if the learner realizes I am drinking too much, s/he often recommends I stop drinking while I am on medications -- and as a patient I often react by being visibly worried/agitated/concerned. Because nothing terrifies me more than the idea that my only coping strategies will be ripped away, I feel a lot less likely to follow up on the learner's recommendations. So as an SP I am really impressed with learners who understand the FIRST first step is replacing (or skillfully reducing my dependence on) unhealthy coping strategies.

• Simplify the plan: When I am depressed, too many choices feel overwhelming. So when learners tell me all the things they want me to do to help me manage my depression (often involving changes to exercise, diet, alcohol/drugs, medications, and/or therapy), as a patient I can feel myself shut down. Any one of those things can be its own major project! A more successful strategy might be limiting the options to the most successful candidates based on what the learner has gleaned about the patient during the encounter. Another good strategy would be to ask the patient: which of these limited options sounds like something I would want to begin when I leave the office? This respects my autonomy even in the midst of a difficult time, helps me feel invested in the plan and motivates me to return for followup.

Summertime

A lazy June day lying over the educational horizon.
[June Day via wikimedia]

Ah, it's the end of the school year. As an SP it is bittersweet in many ways:

• We see such a small slice of students' lives. I often see students more than once, but if they are Y2 students, they can suddenly be ready to graduate, moving onto other programs and cities. When I think about how much they've had to master in such a short time, I am nostalgic and impressed.

• The end of the year changes my feedback sometimes. For instance, during the last OSCE of Y2, I know the students won't go through another OSCE (except for schools who do occasional 3rd year or resident events). So for schools with open feedback, my tone is more informal and summative, more broadly applicable: Congratulations! What have you learned? What are you still struggling with? What specialty are you planning? These skills will help you with that [in a specific way]!

• Summer is when my income plunges. Very few schools have summer events. So I watch my monthly average drop with trepidation and am almost giddy when a random summer job comes my way. When the regular fall schedules start up in August, I'll be ready to jump back in.

• Conversely, summer is when I have the most free time. So I plan my major travels & adventures around this time when possible to reduce the opportunity cost of missing a job during the school year. I'll get to write more, think more. Maybe I'll even get around to reading the Empathy Exams like I said I'd do in January! Yes, I'm looking forward to reading on the porch, drinking homemade iced chai.

Discussion question:
What are your summer plans?

Have you seen something like this before?

An SP having a flash of inspiration during feedback.
[Saint Augustin via wikimedia]

My preferred method for feedback includes a lot of questions. I love feedback when it's a conversation and individualized to each student. I stumbled into a question recently that really makes me happy, especially with Y2 students:

Have you seen this before?

Depending on the conversation, it can mean:

• Have you seen this in clinic?
• Have you had experience with this personally?

I don't know why I didn't think about this before, but the answer is usually yes! Students usually have had some experience in the medical profession before being accepted to most programs. The further along in the program they are, the more likely this answer is to be yes.

So then more questions can follow:

• What did you do/see?
• What tools did you pick up that you used in this encounter?

That's the secret: I don't talk about what they did or should have done in another context. Instead, I direct their responses to reflect how they affected me in this encounter. This both focuses their attention and integrates my feedback with experiences they've already had.

One of the primary complaints students have about SP encounters is how they don't reflect the work the students feel they are capable of outside the exam room. I've been thrilled with how this question changes that dynamic. I can honor the students' actual lived experience and together we can refine it within the safety of the event.

Extra credit:
This turns out to be a useful tool when giving difficult feedback, too. "Your eye contact is poor/You ask too many questions at once/You rushed at the end. Have you heard that before? Has anyone told you that before?" Learners often have heard that feedback before, so it helps to notice the bigger picture and come up with a strategy they can attempt in their next encounter.

Quote of the Day

[Portrait of Henry Ford via wikimedia]

"You can't build a reputation on what you are going to do."

Henry Ford

When I give students feedback about empathy or rapport, sometimes they respond by saying, "Oh, I'm so much better in clinic" or "I'm different with real patients" or "I don't do well when I'm being observed." But I can't give feedback on skills I don't observe.

Feedback models: When you did X, I felt Y

Let X=X.
[De divina proportione via wikimedia]

Another classic SP feedback technique is offering your comments in this format: "When you did X, I felt Y." For example: "When you moved my arm out of your way without saying anything, I felt vulnerable and helpless."

This is the only SP technique I've ever attended a (brief) training on. I know a lot of people hate it because it seems forced and routinized. I resisted it at the beginning, too. But with practice, it's become very natural to me, and now I find it to be one of my most important feedback tools. Here's why:

• I value it for the way it really forces me to truly examine what I felt and why I felt it. It's an excellent tool for self-awareness. The more I know about what makes me comfortable or anxious, the better feedback I can give students.

• Because it focuses on my emotions and observable behavior, rather than the student's motive, it's much harder for a student to argue or dismiss my feedback. This reason alone makes it worth becoming comfortable with the X/Y technique. It keeps the discussion patient-centered.

• I love how it expands my range of expression and allows for more nuanced feedback. Otherwise a lot of feedback is often binary: either good or bad.

• It works for positive and negative feedback equally well. When I tell a student something s/he did made me feel safe and supported, I can visibly see the relief on the student's face. A concrete expression of something that worked well for a patient is as valuable as a comment about something that could be improved.

• It's individual to the SP: different SPs often interpret the same behavior different ways, but express it the same way: "I liked it" or "I didn't like it." Using the X/Y format gives students more information about how their actions are being perceived, which makes the full range of patient reactions more visible.

Though I didn't learn it this way, I also often add: "If you had done A, I would have felt B" like so: "If you had asked me to move my arm, I would have felt like I had some control in a vulnerable situation." This gives students a concrete way to adjust their behavior in response, which I think is critical for good feedback.

However, it can be easy to slip into blame or projection, twisting the format into "When you did X, I felt you were being Y." For instance: "When you asked me the same question again, I felt you weren't listening to me." Assigning motive to a student often leads to a more defensive reaction. Better: "When you asked me the same question again, I felt unheard." When I want to comment on motive, I find it more effective to ask about it directly: "Why did you ask me the same question again?" After the student answers, I can almost always use the agreement technique to redirect and align our goals together without defensiveness.

Homework:
To help me practice this technique in the beginning, I created my own list of Y emotions. I also added a Z category when I needed to shape the conversation around my general values as a patient. I don't use it much anymore, but whenever I work at a new school/event I review it since something unexpected is likely to come up.

Extra credit:
Discovering the concept of non-violent communication a couple of years ago really went a long way towards helping develop the X/Y feedback skill and giving better feedback in general. I really like how it centers itself around empathy. I'm not 100% sold on the whole system, but as a feedback lens I have found it to be very useful.

Time management skills

Time flies.
[Invitation to the Krewe of Nereus Carnival Ball via wikimedia]

We ask students to do a lot in 15 minutes, so time management skills are crucial. When I have students who have a hard time completing the encounter, I frequently give feedback about time management skills. Much of this feedback centers around asking questions & giving directions in clear, concise ways.

This is a living list. Last updated March 21, 2015

• Practice: Students who need more practice asking questions often ask an unfamiliar question in several different ways all as one sentence, which takes up time. For instance: "How can I help you today, what's wrong, what seems to be the trouble?"

• Only ask one question at a time: Don't stack questions. For instance, "Do you drink, smoke or do drugs?" or "What makes it better or worse?" It seems like it might save time, but as a patient, it's difficult to track multiple questions and it may take me time to formulate a comprehensive answer. I may even forget to answer one of them if one of the questions is more important to me than the others. This is especially important if multiple questions have different answers, if there are three or more questions, or if I am in a lot of pain. Plus, as an SP I may have been instructed only to answer the last question, which requires the student to go back and ask the other question(s), anyway. Sometimes one open-ended question can be better than a series of closed questions. For example, "How much do you drink in a week?" gets more information in one question than "Do you drink?" which often needs to be followed up with "How much would you say you drink in a week?" anyway.

• Shifting questions: Similarly, If I don't interrupt a student, I have often found one question can transform into a different question before the student finishes speaking. For instance: "Can you tell me about the quality of the pain, like does it radiate or can you tell me how long you've had it?" If I had interrupted as soon as I heard "quality," the student would have received a much different answer.

• Trailing off: If I don't interrupt a student at the end of a question that is mostly done but the student hasn't actually stopped talking, a student may look at me expectantly and then trail off. For instance: "Have you noticed X or Y... or...." As a patient, I am highly unlikely to interrupt my doctor, so I ask them to finish the sentence; "Or...."? Usually students repeat the question more concisely.

• Repeated questions: In addition to making me feel unheard as a patient, repeating a question uses up unnecessary time.

• Using jargon: If a student uses a word I don't understand as a patient, I may have to ask them to repeat it so I know how to answer. Or I may use other techniques to answer, all of which take more time than necessary.

• Mumbling: Similarly, if I don't understand what the student is saying, I may have to ask them to repeat the word or the question.

• Taking notes: If students don't have good personal shorthand, they may use a lot of time writing out entire sentences with my answers. Even writing "high blood pressure" takes a lot more time than "HBP". The notes students take during the encounter shouldn't be the same ones they will submit as documentation or as part of a SOAP note. Using more abbreviations and symbols will save students time during the encounter.

• Clear directions during physical exams: Clear, simple instructions during physical exams are an easy way for students to save time. Any confusion or misdirection takes time to correct. I find this to be especially true for musculoskeletal & neuro exams.

• Expectations management: As a patient, knowing what to expect is a huge relief and gives me a lot of confidence & trust in the student doctor. Why are you asking this question? What are we doing next? Why is this exam being done? Students often skip this step because it seems to take up precious time -- but I think it's crucial. As above, anything that causes friction and confusion often eats time, so good expectations management usually makes things run more smoothly and quickly.

• Ungowning and draping instructions: similarly, when a student is not clear about ungowning and draping instructions, it can take a lot of time to clarify. If I am uncertain, I may move more slowly. If the student's instructions are unclear, I may not do what the student doctor expects me to do, which requires more explanation. Best practice (ungowning): "Would you please untie your gown and lower it to your waist?" Best practice (draping): "I'm going to lay this sheet over your legs. Please lie back and lift your gown to just below your breasts so I can examine your stomach." 

If students save even just 30 seconds to a minute using these techniques, it may be just enough for them to close the encounter and leave the room before time is called. As a patient, attention to these details also gives me a lot more confidence in them and I will probably feel more comfortable during the encounter.

Extra credit:
During encounters I listen for students who explain a question or exam with more detail after I've expressed uncertainty verbally or nonverbally -- that is almost always a sure sign the student could have saved time by explaining it first more clearly.

Overstepping one's bounds

An SP about to demonstrate her medical knowledge.
[Queen Victoria via wikimedia]

One of the things I keep reminding myself is that SPs are not medical professionals. For instance, no matter how many times we do a gall bladder case, we are not qualified to diagnose cholecystitis.

In fact, I think it's dangerous for SPs to give advice to medical students about anything beyond what they experienced in the encounter unless expressly directed to do so at the event. I cringe when I hear SPs discuss medical feedback they've given students because "I've had a lot of experience with nurses and I know how they do things" or because the SP has experience with the condition s/he is portraying.

This is especially true given our inconsistent training. But it is also in large part because during feedback the power differential is flipped: SPs become the authority, and our words carry a lot of weight, especially with students earlier in the program. But that balance is fragile. If what the SP says conflicts with what students are being taught, all SPs become untrustworthy. We are part of their education but rarely have any actual insight into what they are being taught beyond what we know about our case. Standards and procedures differ at each school, program, hospital, clinic, specialty, etc. And teaching changes all the time, so there is real risk of delivering outdated information.

I also think this attitude is disrespectful to students. Even though SPs should be respected and appreciated for what we have to offer medical students, it's ridiculous to think we are medical experts when the amount students have to learn -- and have already learned -- is so stupendous. Many first-year medical students probably know more about general medicine than most SPs, even those who work several cases a month. Medical students, by and large, are dedicated and bright. We need to make sure we are honoring their educational journey by refraining from the need to prove what we think we know. Of course, some SPs have been or are medical professionals. But I still feel just as strongly that they should not be speaking to students in that role for all the same reasons.

I feel the strength of SPs lies within our ability to focus our comments on the communication skills of the students, not the medical skills. With limited feedback time, I would hope SPs would choose to focus on the details of the interaction rather than medical feedback.

Setting the standard:
At the very least, SPs must identify when they are offering feedback based on their personal medical knowledge, never giving the impression they are speaking on behalf of the program.

Better schools ask SPs to refer students to their lead instructor if there is a conflict between the way the SP thinks a PE should be done or if an HPI question should be asked that isn't on our checklist.

The best schools reinforce this standard and review to make sure SPs are staying within good feedback guidelines.

Communicating sincerity

A student-doctor demonstrating sincerity during an encounter.
[Sterne and Grisette via wikimedia]

I feel strongly that feedback is most effective when it rests on a foundation of observable behavior and offers a concrete way for the student to attempt to fix it.

This can be especially difficult for vague skills like empathy, rapport and respect. Because even if a student doctor knows to say the right thing -- "I'm sorry to hear that" to express empathy, for example -- sometimes it doesn't sound sincere.

So what does that mean? Without concrete observations and recommendations, it's not very helpful to say to a student, "When you said 'I'm sorry to hear that,' it didn't seem sincere" and leave it at that. But it's taken me a long time to really feel like I can describe what sincerity looks like in a helpful way.

So for me, sincerity is when verbal and nonverbal cues match. There are several cues I look for when gaging sincerity:

Eye contact: Does the student maintain or engage eye contact when speaking? If the student is looking away while speaking, or abruptly looks down right after or even while speaking, I will feel as if the student doctor is not sincere. However, if the student looks up and engages eye contact with me while speaking, I am more likely to feel they are sincere. 

Tone: When speaking, did the student's tone change? If the student offers an empathetic statement with the same tone as they use to ask about past medical history, I will feel as if the student doctor is not sincere. 

Expression: Did the student's expression change? Did they raise/lower their eyebrows, blink, tilt their head? Are they smiling or frowning? If the student's expression doesn't change when delivering bad news, expressing empathy, or attempting rapport, I will feel the student doctor is not sincere. For instance, if the student-doctor smiles widely while saying "That's terrible!" I will not feel s/he is sincere.

Rate: Does the student doctor pause for a moment after expressing empathy, or barrel right onto the next question without a breath? Does s/he rattle off "I'm-sorry-to-hear-that" all as one word? If so, that will feel less sincere.

Non-verbal vocal expression: Does the student add a non-verbal vocal expression like "ohhhh", a tongue ticking against teeth, or a sharp inhalation when offering empathy? Do they say "mmm-hmmmm" when attempting rapport or engaging in active listening skills? Those are signals that indicate sincerity.

Posture & Movements: Does the student's posture & movements match what they are trying to communicate? For instance, if we are having a personal discussion, is s/he all the way across the room? Checking their watch? Did they shake their head or nod appropriately? If the student is trying to communicate something serious but is slouching on the stool or leaning against the wall, I will feel the student doctor is not sincere. 

Energy: Is the student matching the patient's level of concern? Are they using a similar rate, volume, emphasis as I am? If the student seems much more upset than I am at a parent's passing, for instance, I will feel the student doctor is not sincere.

Setting the standard:
If the checklist asks me to grade a student on skills like empathy, rapport or respect, I prefer to give them full credit only when they seem sincere.

Feedback models: Feedback Sandwich

The Earl of Sandwich has something to share with SPs.
[First Earl of Sandwich via wikimedia]

Some schools have defined formats for feedback. Many offer open feedback, though: several minutes of wide open time after an encounter to give feedback however the SP sees fit. This can be an incredibly powerful tool -- and completely overwhelming to new SPs.

One easy method to follow for SPs without a lot of experience, or ones who are just starting to refine their technique, is the Feedback Sandwich. It looks like this:

Layer 1: Something the student did well. Save your really good feedback for Layer 3. This is an excellent time to comment on basic skills like active listening, empathy, rapport, pacing, etc. 

Layer 2: Something the student can improve. It is important that this layer is not the largest layer! This layer is most effective when each item contains a recommendation for how to improve. If this is the sort of event that includes multiple encounters for the student, they should be encouraged to practice improving this skill in the very next encounter. 

Layer 3: Something else the student did well. Since this will be the last thing they hear, make it count. Encourage them to keep doing whatever it is they're doing well. Students are often so overwhelmed that SPs can do good in the world just by reminding them they are, in fact, doing well. Sometimes the skills that come most naturally to students can diminish over time because nobody remembers to notice them.

Each layer of the Feedback Sandwich should include concrete examples of observed behaviour during that encounter to illustrate the SP's feedback.

The strength of this format, especially for new SPs, is that it helps focus the feedback rather than jumping around to whatever random thing the SP thinks of next. It creates a basic structure to habitualize observing concrete behavior and balancing the ratio of positive to "negative" feedback. In addition, this can be an especially useful format in scenarios with a very limited amount of time (3 minutes or less): just adjust the number of feedback items per layer to the amount of time you have.

Some people hate the Feedback Sandwich (it's definitely not my favorite). That's okay. It's still a good place to begin. As the SP becomes more comfortable with the Feedback Sandwich, the SP can begin to deviate from this to other models.

Extra credit:
I had no idea Hawaii used to be called the "Sandwich Islands!" I imagine feedback sandwiches on a tropical island would be much more conducive to constructive conversations.

Yes, yes: using agreement in feedback

A disappointed student about to begin feedback.
[Yes or No via wikimedia]

When asking a student for self-reflection during feedback, I find agreeing with the student immediately afterwards sets a tone of mentorship and collaboration right from the start.

Whether the self-reflection was positive or negative, I can still find something to agree with: "Yes, I thought you did that well" or  "Yes, I agree that was the weakest part."

I can agree with a student even if I think they're wrong! If a student says something like "I thought I listened well" and I don't share that assessment, I say something like, "Yes, I'm glad you're paying attention to that! As a patient that's very important to me, too." And then we talk about how they could have done it better.

I have also found agreement is a useful tool when faced with students feeling quite negatively about themselves or the encounter. A natural reaction is to minimize their feelings or try to comfort/console them, but hypercritical students won't be able to hear good feedback until their perspective is acknowledged. So rather than saying "Don't be so hard on yourself!" or "No, you did fine!" instead I try to take a step back: "I understand you're disappointed" or "You seem disappointed" followed by "I know you want to [do the right thing, whatever it is]. As a patient I didn't notice that, though. What I saw was [x]." When I acknowledge the student's disappointment, they noticeably relax and we can continue with constructive feedback.

The value of student self-reflection

So, how did that go for you?
[Jeune Femme au Miroir via wikimedia]

It was a terrible encounter. One of the worst I had ever had. And I had no idea how I was going to talk to the student about it when she returned to the room. Too much had gone wrong, so starting with the positive portion of the feedback sandwich would feel hollow to me -- and I wasn't sure if the student was going to be able to receive it well, anyway.

So when she re-entered the room and sat in anticipation of feedback... I punted. "How do you think you did?" I asked, my heart hammering. She visibly collapsed in a mixture of relief and frustration. "Oh, it was TERRIBLE!" she said. And then she proceeded to talk about all the ways she wish she had done better.

Imagine my surprise and delight: I didn't have to tell her she had done badly! She already knew! So instead of making her feel worse, I could focus my energy on addressing her concerns. What had been a terrible encounter became a very productive one and we both left the encounter feeling better.

That's what cemented my use of self-reflection as the first tool I use in feedback. Some schools probably teach this as a standard approach, but at that point nobody had told me to do it. Engaging students in a healthy dose of self-analysis has served me well for years, even in encounters that have not been as dramatically terrible.

Here's what makes it work:

• Self-reflection helps students take responsibility for their own education. When SPs immediately start with feedback, it's easy for the student to remain passive. Students who are passive in feedback are often more passive in the encounter, as well. I want students to work on their self-analysis during the encounter so that they will be in the habit when SPs are no longer there to provide feedback.
• Starting students with self-reflection allows SPs to begin with a point of agreement -- regardless of whether the student says something positive or negative, the SP can use that as a way of reinforcing or redirecting the resulting feedback. For example: "Yes, I thought you did that well, too." Or: "Yes, I also thought that was one of the weakest moments in the encounter." This helps set a tone of mentorship and respect.
• 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. If you use self-reflection but don't address what concerns the student, s/he is likely to feel unheard, discouraged and resistant to the whole concept. My motto: "Seek first to understand, then to be understood."
• Hearing specifics from students is crucial. Those specifics are what will allow you to make natural transitions into the feedback you want to give. Some students have a hard time getting beyond, "I thought it was fine!" Some are so uncomfortable they move very quickly into "But how do you think I did?" So if a student answers "fine," I follow up with a different open-ended question: "What's something you thought went really well?" or "What's something you wish you had done differently?" I will choose which one to use first depending on the student and how the encounter went. For instance, I might ask what went well if the student seems prone to respond negatively or vice versa. Building your feedback from these specifics is one of the most powerful things you can do as an SP. Students have been most vocally grateful when I have addressed something very specific for that student for that encounter. But pick just one or two things to follow up on. After all, each of us is just one of several SPs they will see. We have limited time and I would rather they feel solid on a couple of things than overwhelmed by several. This is where the feedback hierarchy comes in handy.
• Be willing to lead the feedback. Students lead the encounters, but SPs are in charge of feedback. Without guidance, a genuine self-reflection can lead to rambling. This is not a good use of limited time. If you do self-reflection right, it can look as if the student is leading the feedback, but SPs should know where they want to go while remaining responsive to student concerns and/or questions. Since our time is so limited, that means learning various redirection and transition techniques to help keep the discussion focused and progressing.

I don't think students are often rewarded for self-analysis in med school, but I consider it to be the first step towards skill improvement. So I try to encourage self-reflection in feedback whenever possible, given the constraints of the school, program, time, feedback method, etc.

Feedback hierarchy

Rising to the challenge.
[Monte Cristallo via wikimedia]

SP events have very different methods for student feedback. In places where I can give written or verbal feedback, I have developed a feedback hierarchy to prioritize the limited time I have. Developing a hierarchy allows me to succinctly provide feedback that is both individualized for that particular student and yet consistently reflects my most important values.

This list is ordered in a way which increasingly incorporates more awareness of patient needs at each level. Beginning students are most likely to hear the feedback at the first levels, while advanced students can discuss the higher-level items. If I find a student is defensive in feedback, I often find those students respond better to items lower in the hierarchy.

This is a living list. Last updated January 14, 2015.

Level 1: Domain knowledge
Some schools want you to talk to students about items on the checklist, but some don't. I prefer to spend limited feedback time on communication skills further on in the hierarchy. But if student doctors make mistakes in the history or physical exam to a degree which would be noticeable to a patient, it dramatically affects patient trust and confidence. For instance, if a student doctor hurts me during a physical exam, this is the most important feedback to give. If I feel nervous about how a student doctor handles vulnerable areas like my ears, eyes, or nose, it doesn't matter how empathetic they are. If a student doctor is very disorganized or hesitant when gathering history, as a patient I will feel dubious about their competence. If a student doctor touches me in what a patient could interpret as inappropriate, that's the most important feedback to give (e.g.: a student's knees between my legs, a coat cuff brushing against my breast, etc.).

Level 2: Rapport
Many checklists have a "rapport" item, but nobody ever really talks about what that means. For most SPs, it seems to be a catchall category for "I liked the student doctor" or "The student doctor seemed friendly." But I need more specific guidelines for myself so I can give specific feedback to students. So for me, rapport is about establishing a personal connection with the patient. So when I give feedback about rapport, I comment on posture, tone, eye contact, active listening skills, the use of open-ended questions, using my name, matching my energy, jargon, and communicating sincerity. These things help me feel as if the student doctor is paying attention to me and my nonverbal cues. In addition, if a student attempts to learn/respond to anything about me that isn't medically necessary for them to know (or if they tell me something about themselves), I count that as rapport.

Level 3: Empathy
I always say "empathy first" in encounters, but if students have serious deficiencies in the first two levels, I usually address them in feedback first. To be honest, so few people use empathy regularly that many patients/SPs don't even know it's missing. So empathy is the first of the nuanced skills -- those skills which begin to sort the excellent students from the less adept students. For me, responding to a patient's emotional state is the key to empathy. So when I am looking for empathy, I am looking for student doctors to:

• acknowledge the patient's pain: during the chief complaint, when the patient describes the quality of the pain, when the patient rates the pain, or during a physical exam.
• acknowledge sensitivity for awkward or sensitive questions.
• acknowledge loss or grief: for instance, if family members have died while taking the family health history; if the patient or someone close to the patient has lost a job, etc.
• acknowledge fear or confusion: for instance, during a diagnosis or when the student uses overly technical language.

Level 4: Respect
Respect and rapport are often conflated, but I think you can have rapport without respect and vice versa. Respect indicates an awareness of the patient as an individual worthy of consideration and dignity. For instance, respect includes things like validation, normalization, accommodation, reflective language and transparency. The power differential really comes into play here. Respectful student doctors are non-judgmental, honest, don't interrupt, admit uncertainty, apologize when necessary, take responsibility, keep commitments, and don't make assumptions based on class, gender, sexuality or race.

Level 5: Autonomy
This is one of the things I value most highly. Student doctors who promote patient autonomy prove themselves as trustworthy and make me feel safe. Unfortunately, this is the hardest category for most students because almost everything in medical school (and society at large) rewards the exact opposite of autonomy. I am especially interested in how to facilitate true consent, one where patients feel they have the understanding to make the right decision for themselves and the ability to safely refuse without compromising care. This can be as simple as asking permission to touch a patient and as complex as signing surgical consent forms. So when I give feedback about autonomy, I often comment on the basic tools of summarization and expectations management. In addition, I especially esteem student doctors who go so far as to ask my opinion or invite collaboration. But influencing the way student doctors ask questions is one of my most effective ways to improve autonomy: I want them to ask questions in ways that don't inherently limit the acceptable answers, wait for consent, and keep inviting questions until I am satisfied. Checklists don't usually have a category that would apply to this, so I often lump it into Respect. But I think it is so much bigger than that. You can respect someone but not support their autonomy.