[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.

Pelvic anthem

If "8 Miles Wide" isn't the anthem for pelvic models/educators everywhere, it should be! By the way, this song is not at all safe for work, not even a tiny bit.

"It's not my vagina! It's our vagina!" Godspeed, you brave and valiant vaginas.

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.

Case preparation

An SP prepares for a case.
[study for The Apotheosis of Homer via wikimedia]

Since I work for so many different schools, I've had to develop a case preparation method that is able handle as many different cases styles and expectations as possible.

Cases are often written poorly, with important information scattered or repeated in slightly different ways. Sometimes a case seems clear until a student begins asking questions, at which point you realize you're missing a key piece of information.

So here's how I analyze a case to prepare for an event at any event that follows an OSCE-like model:

• Apply heuristics: In the same way students memorize chunks of questions in order to routinize the asking of them, so do I. So regardless of how the case is written, I review it by looking at the elements categorically. Do I know the answers to the most common HPI questions? Do I know the answers to the basic questions for the patient's history, like... PMH: meds, allergies, surgeries, hospitalizations; FMH: parents, siblings, grandparents; SHx: tobacco, drugs, alcohol, diet, exercise, occupation, living situation. Because none of the schools I work with teach us these heuristics, it took me several years to be able to recognize the categorical details underlying most cases.

• Organize top to bottom: Often symptoms are not written in any particular order that I can see. This is made especially difficult if I need to track symptoms the character doesn't actually have but that students need to ask about for credit. So to help me memorize them, I re-organize them in order from top to bottom. Things like fever, dizziness, and headaches are at the top of the list, things like leg edema are at the bottom. Sometimes I may even draw a little person with appropriate markings to help me visualize the symptoms. I also do this for the PE.

• Create kinetic cues: When re-organizing symptoms, I will also create a gesture for each item. It's pretty easy to forget whether a student has asked about a particular symptom during a long encounter, or after several encounters. Performing a gesture at the same time as I answer the question helps me retain it longer. For instance, if a student asks if I have had a headache, regardless of the answer I may touch my temple. If the gesture is natural enough, the student won't notice it at all. If it's less natural, I may wait until the student is looking down at the clipboard. 

• Create a timeline: This is especially important for cases with a lot of past medical history or social history. It's so helpful to see the progression of things in a clear, logical order.

• Create acronyms: for schools that have social checklist items I tend to forget to watch for during the encounter, I create an acronym to review with myself periodically during the encounter. For instance, sometimes I forget to mentally check if the introduction is complete. So if I am at a school that wants me to track the introduction, empathy, rapport and whether the student used my name, the acronym might be ERIN (Empathy Rapport Intro Name).

• Rewrite: I frequently rewrite cases in ways that make more sense to me. For instance, I may rewrite a case using only positive findings, rather than trying to remember which findings are positive and which ones are negative. I frequently rewrite a case using only the heuristics and use that as my main case review. I may rewrite a case listing differences & similarities between characters if I am doing similar cases at different schools.

Discussion question:
What tricks do you have for preparing, organizing or memorizing a case?

The gendering of imaginary medical professionals

Because women are always nurses, right?
[Train to be a Nurse via wikimedia]

As an actor and a conscientious person, I am interested in our habitual language choices, especially relating to intrinsic human qualities like sex, gender, race, etc.

For instance, there are times during an encounter when a student may refer to my PCP or someone treating me for a particular condition in the case. And almost invariably, the gender of this doctor who doesn't even exist is male. This is true even if the student asking is a woman.

student: "Have you seen a doctor for this condition?"
SP: "Oh, yes."
student: "What did he tell you was going on?"

So I am surprised when, even after all these years, I fall into the same trap:

student: "When did you last see your doctor?"
SP: "I saw him last month."

When I use a masculine pronoun by default, I have to let it go because I don't want to do anything to derail the scenario. But I mentally wince when I hear myself say it.

However, if the student defaults to a masculine pronoun, I can choose to ignore it or challenge it, depending on what feels best for that interaction. For example:

student: "Have you seen a doctor for this condition?"
SP: "Oh, yes."
student: "What did he tell you was going on?"
SP: "She told me to come back for more tests next month."

As an SP, I find I don't even need to add emphasis to "she" or act offended in any way. Just changing the pronoun is enough to change the dynamic and get the student's attention.

It takes a lot of concentration to flip the model and not just go along with it, especially when I'm concentrating on the rest of the encounter requirements, which is why I don't remember to do this as often as I would like. But when I do I feel like I'm helping to create the kind of world I want to live in.

Bonus points:
Other gendered professions in scenarios (a living list): apparently social workers are female, too.

Extra credit:
If a student-doctor uses the term "lady doctor," please call them out on it either in character during the scenario or gently during feedback. (Yes! I've heard it!)

Setting the Standard:
Women can be doctors, too. In fact, nationwide almost 50% of students in medical school are women. I recommend using a feminine pronoun for all imaginary medical professionals to reinforce that possibility and offset the default gendering of medical professionals.

Why "Is that okay?" is not okay

"I'd like to give you some hemlock. Is that okay?"
[Aristotle refusing the hemlock via wikimedia]

As an SP, I care a lot about consent. One of the things I think about is what constitutes true consent, where a patient feels informed & safe enough to make a decision. True consent is the keystone to patient autonomy.

One of the ways I see consent fail in scenarios is when a student doctor asks, "Is that OK?" For instance: "Is it OK if I take notes?" or "I'd like to do a heart exam; is that OK?"

It seems like asking permission would be the right thing to do. But I often hear this question as a ritualized social nicety rather than an invitation to participate, similar to "How are you today?".

More importantly, as a patient, I almost always agree -- even if I'm not sure I should. When someone in a position of authority asks for consent, technically the person has the power to refuse. But that hardly ever happens because it usually seems safer to agree than to challenge the authority, partly due to the power differential. This is especially true if the patient is particularly vulnerable or disadvantaged (elderly, facing language difficulties, in a lot of pain, etc.). As a patient, I don't want to jeopardize the care I need by disagreeing.

If the student-doctor has laid a lot of groundwork of empathy, trust and rapport, it helps smooth the sharp edges of consent. But I think it's more important to facilitate true consent to begin with. So here are some ways student-doctors can ask permission to promote better patient consent:

Wait: Student-doctors are frequently beginning the action while they are asking consent for it. As a patient, this immediately trains me to believe my consent is not important. I'd have to feel incredibly uncomfortable to refuse once something is already in motion.

Inform: Identify procedures before they happen. How can I consent to a heart exam if I don't know what's involved? As a patient, what I think I am agreeing to and what I am actually agreeing to are often quite different. For instance, as a patient I am often surprised to discover a heart exam involves touching four areas on my chest with a stethoscope on the skin. So when I agreed to a heart exam, I didn't understand I was also agreeing to ungowning. I didn't understand my breast tissue was going to be in the way. I didn't know the student-doctor was going to be listening in so many places! It makes me feel tricked and/or ignorant when this happens, neither of which enhances confidence and trust.

Use plain language: I feel frustrated and cautious when student-doctors use jargon when asking consent. "I'm going to palpate your thyroid, okay?" Palpate? Do I even know where my thyroid is? Using simple language is essential for consent, especially when student-doctors will be touching the patient. 

Offer legitimate choices: When I am asked if something is "okay" but I don't know what the alternative is, I feel trapped. "Would you like to lower your gown or would you prefer me to do it?" is a more understandable choice than "Would it be okay if you took your gown down?" Without understanding what the options are, I will probably agree because that seems to be my only option.

Determine comprehension: Consent without comprehension is not consent. I want student-doctors to keep inviting questions until I don't have any more. "What questions do you have?" is a classic, but once isn't enough. The best student-doctors follow up with "what other questions do you have?". The use of summary and teach back can also be really valuable ways to determine true comprehension.

Be prepared to hear no: When a student-doctor asks me "is it okay if..." I can tell they only expect me to say "yes." So why ask the question? Good student-doctors know what Plan B is if the patient refuses -- or don't ask questions where "yes" is the only right answer.

Ask open-ended questions: If "no" is not really an option, an open-ended question is more effective than a closed binary one. For instance, at the end of the encounter, instead of asking "Are you okay with that plan?" a more appropriate question is "How does that plan sound to you?" or "What do you think about that plan?"

Don't ask: Sometimes, asking a permission question which has an obvious answer signals to me the student-doctor feels unsure or uncertain. In some cases it may be better for the student-doctor to give a direction or offer information rather than ask permission -- then adjust if the patient reacts hesitantly. For instance, do I really need to be asked if the student-doctor can take notes? Unlikely.

Paying attention to how to best enable true consent is an impressive way to build trust and respect patient autonomy.

Homework:
In a week, observe how many times you agree to something you don't feel totally confident agreeing to. What keeps you from saying "no"?

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.