An SP waits for the student doctor to finish washing her hands.
[The Sisters via wikimedia]

The introduction sets the tone for the rest of the encounter. When a school requires hand washing for credit, there are two potential moments of awkwardness depending on how the student chooses to wash their hands:

1. If the student uses sanitizing gel, they almost always use too much. Then they either spend a lot of time trying to rub it in, or they shake my hand with their slimy hand. With the first, I lose confidence in the student in the same way as I do when a student uses a tool incorrectly. With the second, I lose trust because shaking a slimy hand is disgusting and it makes me feel that either the student doesn't know that -- or doesn't care about my discomfort. 

2. If the student washes their hands in the sink, there is frequently a long pause while the student says nothing and has their back turned away from me. That makes me feel disengaged. If the student attempts to fill that gap with rapport building, an overview of the encounter, or a review of the doorway information/chief complaint, I feel that time is being put to better use and I have more confidence in the student.

Setting the standard:
To limit awkwardness at the beginning of the encounter, I highly recommend students practice how much hand gel to use to be both clean and efficient. If washing hands in the sink, I highly recommend students practice the ability to talk and wash at the same time.

Joyeux Noël

An SP singing at the holiday party.
[A Christmas Carol via wikimedia]

Whatever you celebrate, may your holidays be both merry and bright.

Communicating sincerity

A student-doctor demonstrating sincerity during an encounter.
[Sterne and Grisette via wikimedia]

I feel strongly that feedback is most effective when it rests on a foundation of observable behavior and offers a concrete way for the student to attempt to fix it.

This can be especially difficult for vague skills like empathy, rapport and respect. Because even if a student doctor knows to say the right thing -- "I'm sorry to hear that" to express empathy, for example -- sometimes it doesn't sound sincere.

So what does that mean? Without concrete observations and recommendations, it's not very helpful to say to a student, "When you said 'I'm sorry to hear that,' it didn't seem sincere" and leave it at that. But it's taken me a long time to really feel like I can describe what sincerity looks like in a helpful way.

So for me, sincerity is when verbal and nonverbal cues match. There are several cues I look for when gaging sincerity:

Eye contact: Does the student maintain or engage eye contact when speaking? If the student is looking away while speaking, or abruptly looks down right after or even while speaking, I will feel as if the student doctor is not sincere. However, if the student looks up and engages eye contact with me while speaking, I am more likely to feel they are sincere. 

Tone: When speaking, did the student's tone change? If the student offers an empathetic statement with the same tone as they use to ask about past medical history, I will feel as if the student doctor is not sincere. 

Expression: Did the student's expression change? Did they raise/lower their eyebrows, blink, tilt their head? Are they smiling or frowning? If the student's expression doesn't change when delivering bad news, expressing empathy, or attempting rapport, I will feel the student doctor is not sincere. For instance, if the student-doctor smiles widely while saying "That's terrible!" I will not feel s/he is sincere.

Rate: Does the student doctor pause for a moment after expressing empathy, or barrel right onto the next question without a breath? Does s/he rattle off "I'm-sorry-to-hear-that" all as one word? If so, that will feel less sincere.

Non-verbal vocal expression: Does the student add a non-verbal vocal expression like "ohhhh", a tongue ticking against teeth, or a sharp inhalation when offering empathy? Do they say "mmm-hmmmm" when attempting rapport or engaging in active listening skills? Those are signals that indicate sincerity.

Posture & Movements: Does the student's posture & movements match what they are trying to communicate? For instance, if we are having a personal discussion, is s/he all the way across the room? Checking their watch? Did they shake their head or nod appropriately? If the student is trying to communicate something serious but is slouching on the stool or leaning against the wall, I will feel the student doctor is not sincere. 

Energy: Is the student matching the patient's level of concern? Are they using a similar rate, volume, emphasis as I am? If the student seems much more upset than I am at a parent's passing, for instance, I will feel the student doctor is not sincere.

Setting the standard:
If the checklist asks me to grade a student on skills like empathy, rapport or respect, I prefer to give them full credit only when they seem sincere.

Empathy vs. sympathy: an animation

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.