Not for the faint of heart.
[Heart diagram from Grey's Anatomy via wikimedia]

The other day a medical professional was taking my medical history and asked, "Do you have heart disease?" And as I always do when a learner asks me that question during a scenario, I thought, What does that mean?

"Heart disease" is such a broad category, and patients rarely refer to their own experiences that way. Patients who have had heart attacks, high blood pressure or high cholesterol may not include those items when asked about "heart disease."

"Disease" is a big part of the problem here, too, I think. As a patient, I wouldn't think to include palpitations when asked this. Or a pulmonary embolism. Does a stroke count? What if I've been told I have HBP or high cholesterol but am not being actively treated for it?

It is especially important to be clear when asking a string of questions to which the answers are usually no. Because as a patient, it is much easier to say "no" than it is to stop the flow to ask a clarifying question.

Extra credit

The term "cardiovascular disease" is even worse. Plain language is important!

Setting the standard

If learners at your school ask broadly about "heart disease," train SPs how to respond realistically and in a standardized way, because otherwise they are almost certainly all giving different answers. Better yet, train learners to ask a broad question about health history first, then to follow up with specific examples based on chief complaint, case and/or presentation.

Maintaining the Mask

A glimpse of the SP under the patient mask.
[Self-portrait with Mask via wikimedia]

When learners feel particularly self-conscious in a scenario, they often break character. This could be because the scenario is new, they're not confident in their abilities, or because a subject is particularly uncomfortable (e.g.: sexual history).

When a learner breaks character, they may talk to themselves, ask the SP a direct question rather than the patient, or make a guess about what they think is supposed to happen in the scenario. It is often accompanied by an expression of appeal towards the SP to get the SP to break character, too. Sometimes they smile to indicate they're in on the joke. I think learners do this because it gives them some control & power in a situation where they feel insecure.

As an SP, it takes a tremendous amount of will to resist or deflect this. So if a learner asks me a direct question like, "So am I supposed to examine your heart?," I have to react like a patient: "I don't know? I guess? I mean, you're the doctor, ha ha!" Or I have to keep a straight face while the learner is clearly looking for more information but hasn't asked for it yet.

Sometimes that's enough pushback for the learner to realize they really do have to pretend to be a medical professional for this encounter. And so we move on.

Sometimes it's not, though. A scenario is a fascinating place that only works when everyone involved agrees to create a shared fantasy. If one person isn't into it, the whole thing limps along until time is called.

That can lead to awkward feedback. In a scenario like that, if I try to give feedback about what I observed, the learner is often defensive. So instead I try to talk with them about why the s/he had trouble taking the encounter seriously. Sometimes we talk about the purpose of scenarios. Even if it doesn't feel real to them, it feels real to me. So the more seriously they treat the encounter, the better feedback I can give.

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.

It's a trap!

How I feel when I don't know an obvious answer my character would know.
[Fox Caught in a Trap via wikimedia]

Dear faculty: when you write a case and are picking professions for your patients, I beg you, do not make me or any of my family members a medical professional/student. It just leads to questions that are difficult for me to answer, like...

• Did you try anything for the pain? (As an SP, unless scripted the answer is "no" which hardly makes sense for most patients, much less a medical professional)

• What do you/your family member think is going on? (It is unusual for a case to contain this information, but answering "I have no idea" makes me sound like a terrible medical professional.)

• What was your MCAT score? (I don't even know the right scale!)

• Oh, what classes are you taking? (Ummm. Anatomy?)

• Oh, what hospital are you working at? (Uh....)

• Oh, your XYZ muscle? ("I'm not sure; it's been a while since I've had to study anatomy. Ha ha!")

• What specialty? (Quick, pick one this student is unlikely to know a lot about!)

&etc.

Having a medical connection makes a student waste valuable time by asking me questions I have to invent the answers to, which could lead to either leading them down the wrong path OR corroding the veracity of the encounter when I am unable to improvise inappropriately. My main technique is to deflect, but even that can seem suspicious, as it is normal for people to build rapport based on similarities.

In addition, when I am written as a medical professional I can't just act like another patient. For instance, I feel I can't evaluate jargon as well because my character already understand the language. I would not be surprised by a mini mental status exam, or many physical exams, or unclear instructions. So feedback about items like that will be necessarily limited from a patient perspective.

Setting the Standard

Unless a case is meant to be interprofessional, keep SP jobs related to the chief complaint/injury or neutral. Pick one that is not highly intriguing to students.

Does that make sense?

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..."

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.

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?