Sure, sure, that makes sense.
[La Lecture via wikimedia]

One of the things I hear from learners during encounters that makes me wince is this:

"Does that make sense?"

This question is problematic in part because it often seems like a formality, like How are you today? or Is that OK? As a binary closed question, there is really only one right answer to keep things moving: yes.

Also, admitting uncertainty is a difficult thing for patients to do. "Does that make sense?" places the burden on the listener for understanding rather than on the speaker for clarity.

"Does this make sense?" can also cast doubt on the confidence of the speaker, as if the speaker is asking for validation instead of confirmation.

I hear this phrase a lot in trainings, too, and as an SP or workshop participant I am unlikely to say "no." In a group, "Does that make sense?" is often met with silence, but silence doesn't actually indicate comprehension.

If someone wants to assess my understanding, the use of open questions like "What questions do you have?" or "What do you think?" is a much better method. Teach back is an effective tool, too. If what you've said doesn't make sense, my response will make that clear.

Bonus points
Other phrases which discourage questions:

• "That's pretty self-explanatory, right?"
• "We all know..."/"I'm sure you all know [x], so..."

Irregular standards: training

An SP with different trainers from different schools.
[In the Draper's Shop via wikimedia]

As I mentioned in Irregular standards: working at multiple schools, specific training for new SPs is often non-existent, leaving you to learn on your own how the training & standards at this school differ from other schools. But even for experienced SPs, different schools handle training in different ways:

For instance, as an SP you never know when you'll receive the case you are scheduled for before the event begins. In a couple of extreme cases, I have received a case on the day I was scheduled to perform it! But usually the range is anywhere between 3 weeks and 3 days before the event. 

Some schools pay for you to learn the case from home while others do not. If you are paid for home preparation, the amount can range anywhere from 2 hours to 30 minutes. 

Some events don't even offer training. Everything you glean from the case is what you will use to perform it. Sometimes you can send questions to the person who sent you the case, but they often go vaguely unanswered. In these events, I always feel like each event is an audition, not a role, and I feel like I'm holding my breath the whole time. 

Schools are inconsistent about when they offer training for cases. Sometimes you're trained on a case just once no matter how many times you do it again, but sometimes you're trained on a case every time no matter how many times you've done it. Sometimes a program that used to train SPs for a particular case stops training for it because they feel like everyone knows it -- but which means new SPs assigned the case are on their own. 

If training is scheduled, it can take a variety of different forms. Sometimes training is scheduled individually, sometimes in a group with others doing your case, sometimes in a group with everyone doing all the cases. Training can be anywhere between 2 hours and 15 minutes. It can be scheduled up to two weeks before the event or just before the event. Only rarely is training more than one session.

Training can include several items, not all of which happen at every school/event (even if they should):

• Contextual overview of case(s) or event in the school's curriculum
• Basic info about the event, like timing, what to do with linens, where to store materials, relevant policies/standards, etc.
• Reading of the case and/or checklist aloud
• Discussion of common pitfalls or issues
• Feedback training
• Physical demonstrations
• Role playing
• Quizzing SPs to check for memorization & consistency

Or it could be a free-for-all where SPs call out questions about their case(s) at random. This is my least favorite format. 

The trainer varies widely at institutions. Some events are trained by a faculty member, sometimes the SP manager, sometimes the head of the educational program, sometimes a Dean, sometimes a TA, sometimes a fellow SP, sometimes a dedicated program trainer.  

Similarly, the skill level of the trainer varies widely. Just like any other instructional event, some teachers are patient, prepared, accommodating and welcome questions. Others are brusque, impatient, or more clueless about the case than we are. Also, SPs can be quite a handful at training if you let them; keeping us on task can be quite a challenge and different people handle that better than others. 

Something most schools are missing, however, is follow through. What happens after the training/event? If the training happens several days/weeks before the event, I appreciate an email with training notes so I remember how the training may have affected my reading of the case. Also, most schools don't have a good feedback loop to make changes to the case after the event: it's nobody's job to compile SP questions and make edits so SPs don't ask the same questions every time. Also, if nobody makes changes to the case based on SP questions, then case drift becomes a real risk -- an invisible body of knowledge about those cases that is inaccessible to any new SP who learns the case.

Extra credit!
Many schools have one or two particular training formats for all their events -- so even if the training is different at each school, at least it's consistent at the school. But one school I work with is all over the map, with almost every possible permutation of the above factors. It's a bit dizzying.

Setting the standard:
My preferred training standard would be a case sent out at least a week ahead of time, with time for questions before the event. SPs would be paid for an hour of at-home prep. Questions would be responded to promptly and the answers coordinated for all at the training held at least an hour before the event. The trainer would be someone who knows how to teach well, and knows enough about the cases to answer most questions about it. The trainer would also be empowered to ask questions of an appropriate faculty member if something unexpected came up during training. SPs could contact the trainer during the event from inside the room to ask a question about the case or grading if necessary. After the event, SP questions would be consolidated and the cases edited before the next event.

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: