[Plato and Aristotle in The School of Athens via wikimedia]

"You can discover more about a person in an hour of play 
than in a year of conversation."

Plato

SP work is not always taken seriously because it looks like we're being paid to play. But I agree with Plato that "play" is a powerful & unique way to learn about oneself and others.

Irregular standards: SP discipline

These SPs don't understand why they're being fired.
[Adam et Ève wikimedia]

One of the worst parts about being an SP is that because SPs are often temporary or tentative contract workers, SPs can be dismissed for almost any or no reason at all.

But schools handle SP disciplinary issues in a variety of ways. Because these processes  -- and the rules it takes to invoke them -- are frequently unspecified when SPs are hired, it leaves us feeling both vulnerable and confused when an issue arises.

Based on my experience, there are several ways schools deal with SP disciplinary issues:

• No warning: Rarely, a school has an SP they know shouldn't be there, but the supervisor(s) never confront the SP due to a fear of conflict or a limited SP program. 

• No warning: More commonly, if a school decides there is an issue with an SP, they just stop scheduling the SP without directly addressing the issue. If the SP then contacts the school to inquire about work after a gap, it is considered an acceptable response to tell the SP s/he will be contacted when work is available -- but without saying it never will be. That misdirection is disrespectful and keeps the SP from finding another job.

• No warning: Sometimes a school fires an SP without communicating the complaint until the time of the firing. This means the SP is unable to remediate or improve performance for that -- or any -- school.

• 1 warning: Better schools directly address an issue of complaint with an SP at least once before firing them. The issue should be presented with kindness, clarity and an expectation of good intentions. If the SP does not improve, the SP knows they will be terminated. That's a lot of pressure to get it right.

• 2+ warnings: The best schools offer an initial warning about the behavior with concrete recommendations for change and a check-in process. If the SP does not improve immediately, one or more additional remediations may be required, each with a clear sense of changes and consequences, including possible termination.

• Infinite warnings: This is also unusual, but sometimes a school continues to give an SP feedback about an issue but the supervisor(s) never follow through with consequences. This can happen with a small SP pool where that particular SP's demographics are rare. But it is bad for learners and may erode standards for other SPs in the pool.

Since SPs are employed so precariously, the power differential means supervisors have a responsibility to act ethically despite the potential for uncomfortable conversations. Schools should role model the behaviors they expect SPs to exhibit to learners during difficult feedback.

As an SP, I want to clearly understand the process for termination for each school. In addition, I want schools to do more to help prevent SP issues from the start. Working in education creates a higher standard for educating employees. Because each school has different and even conflicting details (e.g.: does an SP give feedback about student appearance or not?), new SP training is crucial to keeping SPs from inadvertently breaking a rule they didn't know existed. Good event training (as opposed to irregular event training) would help set appropriate expectations for every SP, every time. And annual reviews would make sure each SP has a clear understanding of areas of improvement before they becomes crises.

Setting the standard:
Schools should offer new SPs training which includes clear expectations for SP behavior as well as the process for remediation and termination. Annual employee training should review those expectations. Individual event training should reinforce standards the school would find actionable. Once a problem is identified, a school should give at least two chances for SP remediation (though not infinite). The SP should be observed in future encounters and given concrete ways to improve performance. If the SP does not improve, the school can release the SP with a clean conscience.

Sit down

An SP resists a command.
[Tor's Fight with the Giants via wikimedia]

During feedback, the learner was quite upset I didn't follow his instructions during the scenario. When faced with a highly charged situation, de-escalation techniques are essential before asking for compliance, or I will feel all of this all at once:

I want my phone. I want to find the papers. I want my mom to tell me everything is going to be OK. I want my boyfriend to die because if he doesn't he is going to kill me. I want to get rid of this blood and the smell. I want someone to tell me what is going on. I want to help. I want to die. I want someone to call me by my name. I want to know what is going to happen next. I want to scream. I want to disappear. I want to fight. I want someone to understand. 

I need to move. I don't want another person yelling at me. I don't want another man pushing me around, telling me to sit down. I can't hear with the blood roaring in my ears. I can't answer these questions. I feel sick. I don't want Ryan to die. I wish I hadn't come home. I wish I had never gotten involved with him. I don't know how I got here, why I took it for so long, how I had the strength in me to finally hit him back. I can't even imagine the life I should have been living if I had never met him but I want it so bad right now I can taste it behind my teeth.  

Am I a bad person because I hit him, or because I let him hit me? Either way, I'm going to be punished. 

The case against empathy

It takes more than empathy to truly understand.
[Harmonie der Geschöpfe via wikimedia]

My first post on Setting the Standard began: "If I could teach medical students only one thing as an SP, it would be to provide empathy first." I'm a big proponent of empathy as a way to reduce the power differential and enhance connection & communication between doctors and patients.

So after I posted "Empathy is the highest form of respect," a friend sent a link titled "Empathy Won’t Save Us In the Fight Against Oppression." I was intrigued. I became even more intrigued when that article referenced "The Baby and The Well: The Case Against Empathy."

In it, Paul Bloom argues, "Empathy has some unfortunate features—it is parochial, narrow-minded, and innumerate. We’re often at our best when we’re smart enough not to rely on it."

Recognizing the limitations of empathy helps me give better feedback to learners. I still believe empathy should be a starting point for patient encounters. But empathy alone is not enough, which is why I also pay close attention to the other values in my feedback hierarchy like respect & autonomy.

In scenarios, a major limitation of empathy is a lack of imagination from the person using it. Frequently, empathy is employed in a fashion similar to the Golden Rule: How would I feel in that situation? But empathy should be more complex and nuanced than that. SP scenarios are a good way to increase learners' exposure to a wider variety of situations than they might otherwise find themselves. But there are situations and lives it is almost impossible for us to truly understand if we haven't lived them. This is especially true for vulnerable & marginalized patient populations.

So when empathy fails, respect and unconditional positive regard can fill the gap. Bloom writes, “Our best hope for the future [lies] in an appreciation of the fact that, even if we don’t empathize with distant strangers, their lives have the same value as the lives of those we love.” That's always good feedback to give learners.

Actor Seeks Role

All I can think of when I watch the SP-inspired "Actor Seeks Role" is how ironic it is that we work in the health industry but have so little access to health care:

This short film is much funnier and more tragic than when I wrote: "SP encounters are not a substitute for medical care." It's so easy to forget that SPs are considered temporary workers at best, and not eligible for the kinds of benefits other employees receive. Only one school I work with allows SPs to access medical care at their institution (which is, quite honestly, a big reason why SPs work at that school).

The Affordable Care Act really made a big difference in my ability to continue to contribute as an SP without living in constant fear of debilitating medical bills. I sure would like it better if schools were willing to include us on their health plans, though, or access to their care at a reduced rate.

Extra credit:
Of course, it's also charming to see how another SP studies, performs, and grapples with how to be a serious actor while being paid to be a pretend patient. Even while obviously exaggerated, it's certainly more realistic than that Seinfeld episode.

The point of greatest vulnerability

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!