Yes, I want to see more cross-pollination and artistic collaborations like Bedside Manner!

From the artist's website: "Bedside Manner is a series of photographs and an 18-minute video that explores the little-known world of standardized patient simulations. Standardized patients (SPs) are professional medical actors who are trained to present particular sets of symptoms in order to help medical students improve their diagnostic skills and bedside manner. Routinely, SP encounters are filmed and evaluated by medical professors who observe the interaction of student and medical actor through a one-way mirror."

I am delighted Corinne May Botz got permission for this series. Botz is also the author/photographer of "The Nutshell Studies of Unexplained Death," which explored the groundbreaking crime scene dioramas of Frances Gleaner Lee in the 40s and 50s.

I really wish I could watch the video, which doesn't appear to be available on her site or linked from the New Yorker. According to Botz, the video "deconstructs a real-life standardized patient simulation. It also creates a complex portrait of the neurologist Dr. Alice Flaherty, who plays herself as a doctor, standardized patient and real patient." Intriguing!

I think I am most interested in exploring this further: "...acting and staged representations inform the interaction between patients and doctors in important ways. In order to express their suffering, real patients must learn how to act in doctors' offices." This is very insightful. Reminding learners that patients are "acting," too, may be of use to them. The more learners are able to demonstrate empathy, validation, confidence, respect and autonomy, the less likely patients are to feel the need to "perform" to demonstrate their distress.

In fact, I am strongly reminded of a blog post called "Performance Anxiety" about how an obese patient feels the need to be "terrifically cheerful" in order to receive adequate care. "...being cheerful and upbeat simply works to get a better quality of care in almost every instance. But it’s also enormously taxing, because it is, after all, a performance. Going in for my ultrasound appointment, I was nervous as hell, but I also knew that as soon as I met with the wand-wielder I’d have to push all that worry away and take on a lighthearted, friendly, cheerful persona if I wanted to be certain I’d be treated like a whole person... this pressure to perform under what are at best extremely uncomfortable circumstances does add an additional layer of stress... I resent having to put this happy-fat-lady caricature on. But it’s the most reliable method I know for securing good customer service when I’m meeting a specialist or any new-to-me medical professional for the first time."

New inspirations

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.

Mind The Gap

The majestic horror of an on-call schedule.
[Grand Canyon of the Yellowstone via wikimedia]

SP schedules are highly unpredictable and mutable.

This instability is one of the reasons why we should be compensated well. As I wrote in Herding Cats, "SP work is meant to be flexible, but in reality many schools maintain a pool of 'reliable' (by which they mean 'available') SPs. If you are unavailable too often it can count against you. I think this is a bit unfair for a profession that offers no benefits, security or regular work."

So articles like this one about The Gap, which is rejecting an even worse on-call approach, are of great interest to me.

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 Silent Curriculum

Flinching from the silent curriculum.
[Susanna and the Elders via wikimedia]

I love "The Silent Curriculum" so, so, so much. It's powerful and true and brave. Go read it. Go!

I referenced similar issues in my "Beyond the classroom" post:

"SPs are only one tiny influence in a medical student's education. What school students pick, what attitudes they arrive with, who their mentors are, their internships, their residencies, the laws they practice under, and the insurance industry all influence the kinds of medical professionals they become. Almost all of these things are outside their control, and certainly outside of mine. So yes, to be effective, medical educators should be role models. I would feel better if I knew the skills SPs teach students were being reinforced at all levels."

I think one of the things Katherine Brooks writes that is particularly important is this: "I allowed myself to participate in the unconsented care of patients and prioritized my learning, evaluations, and reputation over my values."

I know when faced with personal self-preservation, I am not always the advocate I should be. I am sensitive to explicit vs. implicit rules; that's part of what makes me a good SP. But I feel at my most helpless when faced with bureaucracy where the culture does not match the mission and I have no safe way to express it.

It also makes me realize that while I love the traditional 15-minutes-in-a-room-with-a-student-doctor, the scenarios and schools I am really impressed with are the ones that focus on interdisciplinary & team scenarios. How medical professionals treat each other very much affects how they treat patients. Core values like power differential and consent are ten times worse when working within an institutional infrastructure. How can we expect people to treat patients better than they themselves are treated? While some may be able to do so in the short term through sheer force of empathy, it is not sustainable in the long term, and the medical profession suffers for it.

So the first time I was in a scenario which specifically requested students to challenge each other, my heart almost burst with happiness. I hope to see more of these kinds of events as time goes on. As learners are encouraged to practice challenging and accepting challenges to authority, I hope to contribute to a culture that values a spectrum of diverse voices and views.

Setting the Standard:
Create scenarios to help learners make decisions in teams in ways that encourage challenging each other or gracefully accepting criticism. Reinforce these aspects of scenarios even when they are not the primary objectives. These skills can and should be practiced in safe spaces where grades, jobs or professional relationships are not at risk.

Using Google Glass

Earliest known depiction of a student using Google Glass.
[The "Glasses Apostle" via wikimedia]

I was going to scoff when I ran across this report preview:

Recording Medical Students’ Encounters with Standardized Patients Using Google Glass: Providing End-of-Life Clinical Education

Until I read "traditional wall-mounted cameras...provide a limited view of key nonverbal communication behaviors during clinical encounters."

Ah! Yes! That is totally true. When I review video encounters, without a good look at the student's face, grading things like eye contact & sincerity becomes much more difficult.

"Next steps include a larger, more rigorous comparison of Google Glass versus traditional videos and expanded use of this technology in other aspects of the clinical skills training program."

Indeed. I am thinking of the cost-benefit ratio, though. The results have higher fidelity, but do they justify the cost and cognitive dissonance during their use? I guess that depends on what the program uses the resulting videos for. Data without analysis is a waste of resources.

Bonus points (added August 2015)

• I've now been in an event that includes these glasses! I don't know what happens with the video, but the glasses just looked like safety goggles, the kind you might wear to protect your eyes from bodily fluids. In the context of this particular event, it wasn't that incongruous, though it probably would have been in a traditional patient room.

• I've also been at events that use Go Pro cameras attached to the learner, which also seems like an interesting strategy.

SP community site?

An SP looking skeptical but intrigued.
[The Detective via wikimedia]

Well, hello, there! Does anyone know anything about http://www.standardized-patient.org/ ? It's exactly what I've been looking for for years but it doesn't quite feel right and I can't put my finger on why.  Maybe: "All content becomes property of the website"? Maybe: one of the most active members seems to be a spammer? Maybe: I can't tell what school or consortium is behind it? (I'd feel more comfortable if a legitimate organization like ASPE was behind it.) Where did it come from? Why is it here? So many questions, not enough answers -- or activity.

[updated 02/28: most of the members have been removed. Hmmmm. Updated 03/09: many more new members, all of whom seem to be spammers. Dang it!]

Rejection

An SP flees after an unsatisfactory experience with a student-doctor.
[Sita Bhumi Pravesh via wikimedia]

This Atlantic article is written from the perspective of marriage, but it helps crystalize a particular (dis)connection dynamic I experience with some students:

"Throughout the day, partners would make requests for connection, what Gottman calls "bids." For example, say that the husband is a bird enthusiast and notices a goldfinch fly across the yard. He might say to his wife, "Look at that beautiful bird outside!" He's not just commenting on the bird here: he's requesting a response from his wife -- a sign of interest or support -- hoping they’ll connect, however momentarily, over the bird. 

The wife now has a choice. She can respond by either "turning toward" or "turning away" from her husband, as Gottman puts it. Though the bird-bid might seem minor and silly, it can actually reveal a lot about the health of the relationship. The husband thought the bird was important enough to bring it up in conversation and the question is whether his wife recognizes and respects that. 

People who turned toward their partners in the study responded by engaging the bidder, showing interest and support in the bid. Those who didn’t—those who turned away—would not respond or respond minimally and continue doing whatever they were doing, like watching TV or reading the paper. Sometimes they would respond with overt hostility, saying something like, "Stop interrupting me, I’m reading.""

Students rarely respond with hostility, of course. But when they don't engage when I make a "bid," that makes me feel as if the student-doctor doesn't care about me as a patient. For instance, if I talk about my pain and the the student moves onto the next question without acknowledging it, s/he has rejected my bid. If I talk about my kids, my job, or a funny thing that happened to me but the student doesn't engage with it, s/he has rejected my bid.

Ignoring my request for connection (or responding insincerely) is very likely to affect the student's empathy and/or rapport scores.

History lesson

A senior faculty member observing an SP encounter.
[Man Holding a Caduceus via wikimedia]

Happy New Year! For Christmas this year I got several SP books, so expect to see quotes/reviews in the future from such thrillers as "Coaching Standardized Patients, "Training Standardized Patients To Have Physical Findings," "Objective Structured Clinical Exams," as well as the new SP classic "The Empathy Exams."

But first I wanted to direct your attention to an article by the esteemed Peggy Wallace: "Following The Threads Of An Innovation: The History Of Standardized Patients In Medical Education" published in 1997. How delightful! I appreciate having an authoritative source to refer to. Here's a brief summary:

"Today, as we enter the new millennium, the standardized patient has become one of the most pervasive and highly talented of the new methodologies in medical education. It was certainly not always so. The standardized patient was anything but welcome and readily excepted educational tool, especially in the early days." Though the use of SPs began in 1963, it was not until 1985 that the traditional OSCE begin to integrate SPs, and even then its dissemination was slow. National boards (USMLE Step2) didn't incorporate SPs until after the article was published!

There were 3 primary contributors to the standardized patient field:

* Howard S. Barrows was the first to use SPs at USC. "Almost never was there a student whose clinical skills were evaluated as unsatisfactory because the faculty almost never directly observed the student with patients. In fact until the advent of standardized patients, there was no objective clinical measure by which to evaluate students." It's fascinating to learn that Barrows went on to teach at McMaster University, which has similarly transformed medical applicant interviews through the MMI. While at McMaster he developed the small group format and the use of USPs. He developed ways of simulating difficult findings on SPs like bruits and pneumothorax. He was the first to develop encounters with difficult patients: seductive, angry, inquisitive, etc. 

* Paula Stillman created specific checklists at the University of Arizona. For instance, what does "examine the eye" mean, really? Stillman could tell you 20 things a student should do to examine an eye that nobody had bothered to standardize before. In addition to using SPs as a body and an evaluator, she also used SPs to teach those skills: "They knew nothing about medicine. They were strictly process people." And yet still effective, I imagine, with the appropriate training! She was the first to begin working with patients with actual physical findings (only one school here does that). 

* Robert Kretzschmar began using SP models as "gynecological teaching associates" in 1968. At first they were just bodies with a sheet obscuring their face and without commentary or feedback, but Kretzschmar expanded the teaching & communication roles for GTAs in 1972.

Things which did not come to pass:

* "The 'patient instructor' might become a necessity rather than a luxury --  and Standardized Patients might be even more extensively needed for clinical learning and self-assessment as the pool of teaching faculty dwindles." (Not without better training!) 

* "And what about the practicing physician, or the one who has lost his license to practice? Might not the standardized patient be able to support the physician in new learning... [making] it possible for the physicians-in-trouble to relearn?" (While I would love to see more of this, I only know of one program that works with physicians-in-trouble and it's a very small, closed group.) 

* One of the interesting skills that seems to have been lost over the years is the use of "stimulated recall" after the encounter. SP feedback can be great, but I imagine reviewing a video of the encounter with an expert guide to ask you questions at specific points would be incredibly effective. (I try to do something similar in my feedback -- e.g. "What were you thinking when X happened or when you asked X?" -- but I'd like it to be a standard tool for schools to use when appropriate.)

Thank you, Peggy Wallace, and thank you, Barrows, Stillman & Kretzschmar! As Wallace concludes, "May that golden rod, now firmly planted, continue to inspire winged ideals in the midst of the inevitable conflict of the opinons that will create the fertile soil for sustaining educational efforts as the search goes on for a better way to support the healers of today – and nurture those of tomorrow."

Getting a clue

An SP giving a clue card to a student after a heart & lung exam.
[Detail from Card Players via wikimedia]

Obviously, most SPs do not match the physical findings of the cases they portray. There aren't enough of us to specially cast in cases which include findings like heart murmurs, abdominal masses, retinopathy, swollen lymph nodes, clubbing, etc. And despite the fascinating and helpful tips in "Training Standardized Patients To Have Physical Findings," it is almost impossible to simulate these findings, either.

So I usually give student doctors a card that explains the finding after they've finished an exam which might reveal it. Each school has a different method for doing this. Students are usually visibly triumphant when they receive a card, as if they have won a prize.

However, student doctors almost never share that finding with me as a patient. Once they get a card that describes the abnormal results of a tactile fremitus exam, for instance, they continue with the rest of the exam as if nothing had happened!

I find this tremendously frustrating as an SP because they lose out on the chance to practice giving findings that are not within normal limits without alarming patients. I want them to practice offering contextualization, risk or reassurance in these situations, to help me understand why the finding relates to my chief complaint. Without that practice, they will be behind the curve when it happens to them later.

Beyond the classroom

A medical student in the midst of medical education. SPs are the third wave from the left.
[The South Ledges, Appledore via wikimedia]

I feel bad when I read articles like "5 Simple Habits Can Help Doctors Connect With Patients" because of quotes like this:

"Our medical teachers put a premium on accuracy and efficiency, which became conflated with speed. Everything had to be fast. In 2014, doctors still value speed and technical accuracy, but we also do more to consider the quality of care we give and whether patients are satisfied with it."

As much as I love what I do and how much I value communication skills, when I read this I feel like we ask doctors to do more and more with less and less. In many medical school scenarios we have between 12-15 minutes for each scenario. What sort of meaningful connection can be made in that time? In practice, doctors can't take much more time than that or they risk disrupting an already overbooked schedule.

Also:

"Medical educators should be role models for these common courtesies... Trainees take their cues from us. These behaviors are what constitute 'bedside manner.'"

SPs are only one tiny influence in a medical student's education. What school students pick, what attitudes they arrive with, who their mentors are, their internships, their residencies, the laws they practice under, and the insurance industry all influence the kinds of medical professionals they become. Almost all of these things are outside their control, and certainly outside of mine. So yes, to be effective, medical educators should be role models. I would feel better if I knew the skills SPs teach students were being reinforced at all levels.

Unannounced SPs

USPs arrive at a clinic evaluation.
[Unexpected Visitors via wikimedia]

I loved the specificity and the intent in this study published April 2014: "Unannounced standardized patients: a promising method of assessing patient-centered care in your health care system" by Sondra Zabar, Kathleen Hanley, David Stevens, Jessica Murphy, Angela Burgess, Adina Kalet and Colleen Gillespie. (whew!)

"Implementing a USP assessment can help clinical settings move beyond patient satisfaction as a measure of performance and focus more on targeted assessments of the quality of care provided."

Oh, my, yes! I would love to be a USP. SPs are especially qualified to offer real-life quality assurance in a variety of settings: "USPs can be trained to be consistent and accurate raters of clinical performance and clinic functioning through the use of highly specific, behaviorally-anchored checklists. They also have the benefit of exposure to a wide variety of levels of performance and training in expectations and standards of quality, experiences most 'real' patients do not have... Such reliability and validity, combined with the standardization of clinical cases and patient portrayal, is particularly useful for comparing performance over time or across clinical units."

One of the concerns, of course, is what the study endearingly calls "the ethics of deception." As someone who very much values transparency, I think this is a valid concern. Unlike medical school, where students are aware that SPs are playing a role, USPs are "unannounced" and so have the potential to contribute to a sense of paranoia and mistrust -- both of which contribute to a toxic environment for employees and patients. Transparency, in this case, should mean that everyone involved knows the use of SPs is a regular part of the quality improvement process -- and that everyone involved gets to see the outcomes in a reasonably timely way.

Phone services would be another excellent use of SPs. For instance, I had a recent disappointing encounter while setting up an appointment. I had to call three times before finding someone who could help me. Thanks to my SP experience, I was able to offer concrete, non-inflammatory feedback -- and I was pleased to be able to end with positive feedback for the one helpful representative (feedback sandwich, yo!). But what really would felt satisfying is knowing my experiences could lead to improved outcomes for other patients calling the service.

Extra credit!
I learned a new name for an old concept: The "Hawthorne effect" describes how the awareness of being assessed influences the care provided.

Assigned reading:
Also, see this article: "Why we need 'mystery shoppers' directly observing health care"

SP encounters are not a substitute for medical care

I hear the GU exams feel sort of like this.
[Opisthotonus in a patient suffering from tetanus via wikimedia]

It's important to recognize satire when you see it:

Standardized Patient Suing Medical School After No One Detected Prostate Cancer

I probably get between 600-800 exams a year from various medical students. One of my favorite things about encounters that include physical exams is seeing the large range of findings between student doctors. My blood pressure is excellent but every student comes up with a different number. I have incredible reflexes if student doctors hit the right spot, but less than half of them do. Very few guess my age or weight correctly. I remember one group of students was once very concerned about something that turns out to be very normal in women.

One of the unanticipated side effects of this job is the constant battle against hypochondria: is it fatigue or is it CANCER? But because I have so many exams, I feel lured into a false sense of security. Even though I know these exams are cursory at best, I also haven't been to an actual doctor in... years. I need to change that.

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.

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.