I loved this animation about empathy (one of my core values!). Student doctors are often so uncomfortable with my emotional discomfort that they want to fix or minimize those feelings. As a patient that often makes me feel worse, as if I am not allowed to be emotionally honest with my doctor. Then I feel like I have to take care of the doctor rather than the other way around.

According to the video, empathy includes:

• perspective taking
• staying out of judgment
• recognizing emotion in other people
• communicating that emotion

I like how this expands my view of empathy and gives me more ways to talk about it with students. I especially love when the video points out the use of "At least..." as an empathic terminator.

Homework:

Listen for ways your emotions are being received or deflected over the course of a week, even (especially?) by people you are close to. How does that make you feel? What would make you feel better?

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.

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.

Applied skills: communications breakdown

Not a good time for feedback.
[Fighting horses via wikimedia]

One of the ironic things about what I do is that I am paid to evaluate communication skills -- but in a way that is generally unsupported outside the confines of an SP encounter.

I have been trained to observe things like eye contact, body posture, tone. I notice empathy and rapport skills. I am keenly aware of power dynamics and language that contributes to subtle coercion. I am attuned to actions that indicate engagement and responsiveness.

So when I experience difficult situations outside the exam room, situations in which a lack of communication skills is contributing to a negative situation, I don't know what to do.

I now have language to describe why I am uncomfortable to myself. Honestly, this is a hugely useful tool. Awareness of what makes me uncomfortable and why can sometimes be enough to ride out a difficult encounter.

However, most of those situations don't allow me to communicate my distress without negative consequences. During typical SP feedback, there is a willing suspension of defensiveness which makes constructive comments possible. Of course that is a fragile balance and can easily be upset with the wrong approach. But where else in life do you get the chance to comment on how to improve a difficult encounter?

I wish there were more opportunities for that, because observing the behavior without being able to comment on or resolve it makes me feel helpless sometimes.

Quote of the day

[Portrait of Pablo Picasso via wikimedia]

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

Pablo Picasso

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

Different event styles

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

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

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

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

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

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

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

Discussion question:
What scenario formats does your school use?

Hand wash

Lady Macbeth could teach us a few things about hand washing.
[Ellen Terry as Lady Macbeth via wikimeda]

One of the things I have become more aware of since becoming an SP is how hard it is to stay healthy in the health profession! Students generally can't make up scenario events, and so they enter my room in various stages of illness and fever.

So now I am much more aware of handwashing -- both theirs and mine. Since I shake so many student hands, I try to wash them between students. I am more careful about rubbing my eyes. I use a paper towel to open the bathroom door after I've washed my hands. I use the back of my wrist to shut off the water. When I handle pens or my phone I want to wash my hands. Sometimes I sanitize the keyboard I am using for checklists.  I even use the sanitizing gel more than I used to, though I primarily prefer soap & water.

When we are in flu season, my handwashing urge kicks into overdrive. But it must be working, because it's been a while since I got the flu, despite persistent contact with potentially infected students.

Discussion question
Does your school have a checklist item for "Student washed hands"? If so, what are the criteria for full credit? Can students use hand gel? Do they have to wash their hands in front of you or outside the room? Do they have to wash their hands immediately before beginning a physical exam? Etc.

Extra credit!
I once had a student in a group setting who refused to use hand gel because she claimed to be allergic to it. In this location there was no access to water. So I allowed her do the physical exam but it made me squirm. Only afterwards did I realize I should have asked her to use gloves instead.