A learner carefully prepares to hear feedback.
[The Goose Girl via wikimedia]

I've written about the value of student self-reflection before. My goal for feedback is to finely tune it for this encounter for this learner, and so I usually begin with the standard open-ended question "How did that go for you, [name]?". Since I always have a ton of potential feedback but a very limited amount of time, I begin this way in part because I value knowing what direction the student wants to go, as I wrote below:

"For me, this is the most important part of using self-reflection: be genuinely interested in the student's response. When I ask, "How did that go for you?" I am not waiting for a perfunctory answer so that I can launch into my own feedback. I am waiting to see where (or if) our needs overlap."

This method and focus developed intuitively over many years, so when I heard Valerie Fulmer say this recently, I felt something click sharply into place along with a deep sense of validation:

"The first thing a student says [when feedback begins] is the point of greatest vulnerability."

Yes! "The point of greatest vulnerability" really helped crystallize why I approach feedback in this way. Now that I know this explicitly I can be even more strategic about how I respond to the student's response, including how I employ agreement in feedback. Also, maintaining "vulnerability" as a keyword helps me remain in a state of compassion during feedback, even if faced with a difficult encounter or student.

Bonus points (added 08.28.2015):
I just had to remind myself of this recently, in fact: a learner came into my room for feedback and before I said anything immediately exclaimed: "That was SO AWKWARD!" We laughed briefly and I was about to "begin" my feedback with the standard "So how did that go for you?" when I realized she had already told me how that went for her: awkwardly. That was her point of greatest vulnerability. So I began my feedback by saying "So what made that awkward for you?" instead and we had a great conversation.

There's an app for that

A patient completing a student feedback survey.
[Portrait of Nicholas Thérèse Benôit Frochot via wikimedia]

Medical students at the University of Pittsburgh are developing a patient feedback app: "The app allows both patients and students to rate how they think an appointment went. Patients also can give feedback on how the student performed."

Honest feedback from patients is a noble goal. I would love to contribute to a system where patients felt they could offer honest feedback and know they had been heard.

Some issues I see:

• Data without plans for followup, development, training and/or mentorship is useless. Don't bother collecting data until you have plans to do something with it. (I feel this way about SP checklists, too.)

• It's very difficult for a patient, who has a huge emotional investment in the experience and the outcome, to step back and offer kind, trustworthy, respectful feedback to learners. Even SPs often have trouble doing this, and we're only pretending to have the experience!

• Patients can be expected to ignore the parts of the feedback they don't care much about to focus on the thing that really bothered them. That makes the data less useful. (This is true for SPs, too.)

• When is the survey administered? Feedback about any encounter should happen as soon after an encounter as possible, so that both parties remember the details. If the patient is asked to do it at home, after the encounter and after the patient has seen several other medical professionals, the patient is going to give less reliable feedback.

• If the app is something a patient is expected to download and use on their own phones, that will further reduce the usefulness of the survey. Plus, a smartphone app only reaches those who can afford smartphones. I hope the system can be adapted so those who don't use smartphones can still have a say.

Also: "Students already get feedback from what are called standardized patients — actors who are assigned a specific situation and medical illness. But according to Patel, that feedback is mostly objective: Did they wash their hands and avoid medical jargon? Students are often left with a lot of unanswered questions."

That may be true at the University of Pittsburgh, but it's not true everywhere. In fact, I would say that limiting SPs to objective feedback limits the full potential of SPs. However, the subjective feedback must be very capable to be effective. To do it well, SP must be trained to articulate their experiences in ways patients cannot (due to things like the power differential as well as a general lack of constructive feedback training or emotional analysis).

Also, more SP encounters could help. Many schools only offer end-of-the year testing. In high-stakes exams most students are focused on the outcomes, not the feedback. The advantage of the app is that students would ideally be receiving a consistent stream of feedback throughout their clinical experiences, which gives them more opportunities to notice patterns and make changes. Imagine what could happen if students saw more SPs over the course of a year!

Quote of the Day

[The assumption of Mary via wikimedia]

"Empathy is the highest form of respect."

Lisa B. Marshall

I have yet to write a separate post about evaluating respect, but in the Feedback Hierachy post I wrote:

"Respect indicates an awareness of the patient as an individual worthy of consideration and dignity. For instance, respect includes things like validation, normalization, accommodation, reflective language and transparency. Respectful student doctors are non-judgmental, honest, don't interrupt, admit uncertainty, apologize when necessary, take responsibility, keep commitments, and don't make assumptions based on class, gender, sexuality or race."

But since empathy is one of my core values, I find Lisa B. Marshall's quote fascinating. What do you think?

Uptalk?

I'm not sure? If this is serious?
[Sibilla via wikimedia]

"Did the student seem confident?" is one of those subjective questions SPs are often asked to answer on checklists. So when student-doctors frequently end their sentences as if they are questions?  I often advise learners to limit their use of "uptalk" during feedback.

As a patient, excessive uptalk causes me to lose confidence in the student-doctor because it can come across as if s/he is uncertain or seeking validation. This is especially true if the uptalk is paired with other signs of deference, like cocking his/her head to one side.

Nonverbal cues strongly affect patient trust & confidence. Learners often expressive gratitude when given feedback about things like tone & posture because they are often invisible things learners can change which have real impacts on patients.

Uptalk can be controversial, however. I recognize it is often gendered: I give women this feedback more than men, and women are more often socialized with habits that undermine their authority. But learning to project respectful authority & appropriate confidence are keys to navigating the power differential between doctors and patients. So when I give feedback to learners about uptalk, I try to keep it as neutral as possible. Sometimes we replay and reframe sentences that stood out during the encounter. I don't expect to change a lifetime of vocal inflection in one session, but awareness is always the first step.

Do you have heart disease?

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.