Standardized: a web series by SPs, for SPs. Watch the pilot below:

Elderly simulations

An elderly patient patiently waits for her appointment.
[Portrait of an Old Woman via wikimedia]

Some people still say you can't practice empathy, that people either have this as a skill or they don't.  I disagree, which is why I like these elderly simulations in Poland:

Medical student Ludwika Wodyk fumbles her way slowly down the stairs, her movements encumbered by heavy strapping around her limbs and body, her vision distorted by special goggles. She is one of a group of medical students in Poland being given the chance to experience first-hand how it can feel to be an aging patient.

Empathy is something that can be taught, or at the very least, experienced. For many people, empathy is highly contextual, so direct experience with a problem can often give them insight into the barriers or complications of a particular population. This brings benefits like understanding, tolerance, and more creative problem-solving when the same circumstances arise again.

Elderly simulations can also be found in Britain and at MIT.

Extra credit:
When I roleplay older patients, I usually focus on the visual aspects. In future scenarios I want to pay more attention to the physical aspects and give feedback from the perspective of a person who might also have mobility, sight and hearing challenges as well.

Quote of the Day

[William Osler photograph via wikipedia]

"It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has."

William Osler

Osler was one of the four founding professors of Johns Hopkins Hospital. He established the practice of residency. Before Osler, med students could go on to be doctors without having seen a single patient!

Bedside Manner

Yes, I want to see more cross-pollination and artistic collaborations like Bedside Manner!

From the artist's website: "Bedside Manner is a series of photographs and an 18-minute video that explores the little-known world of standardized patient simulations. Standardized patients (SPs) are professional medical actors who are trained to present particular sets of symptoms in order to help medical students improve their diagnostic skills and bedside manner. Routinely, SP encounters are filmed and evaluated by medical professors who observe the interaction of student and medical actor through a one-way mirror."

I am delighted Corinne May Botz got permission for this series. Botz is also the author/photographer of "The Nutshell Studies of Unexplained Death," which explored the groundbreaking crime scene dioramas of Frances Gleaner Lee in the 40s and 50s.

I really wish I could watch the video, which doesn't appear to be available on her site or linked from the New Yorker. According to Botz, the video "deconstructs a real-life standardized patient simulation. It also creates a complex portrait of the neurologist Dr. Alice Flaherty, who plays herself as a doctor, standardized patient and real patient." Intriguing!

I think I am most interested in exploring this further: "...acting and staged representations inform the interaction between patients and doctors in important ways. In order to express their suffering, real patients must learn how to act in doctors' offices." This is very insightful. Reminding learners that patients are "acting," too, may be of use to them. The more learners are able to demonstrate empathy, validation, confidence, respect and autonomy, the less likely patients are to feel the need to "perform" to demonstrate their distress.

In fact, I am strongly reminded of a blog post called "Performance Anxiety" about how an obese patient feels the need to be "terrifically cheerful" in order to receive adequate care. "...being cheerful and upbeat simply works to get a better quality of care in almost every instance. But it’s also enormously taxing, because it is, after all, a performance. Going in for my ultrasound appointment, I was nervous as hell, but I also knew that as soon as I met with the wand-wielder I’d have to push all that worry away and take on a lighthearted, friendly, cheerful persona if I wanted to be certain I’d be treated like a whole person... this pressure to perform under what are at best extremely uncomfortable circumstances does add an additional layer of stress... I resent having to put this happy-fat-lady caricature on. But it’s the most reliable method I know for securing good customer service when I’m meeting a specialist or any new-to-me medical professional for the first time."

Using collaboration with patients

An SP and a learner collaborate together.
[The Duet via wikimedia]

Collaboration is a tool learners can use to reduce the power differential and invite the patient into the conversation.

Collaboration engages the patient with questions that explicitly offer the patient input into treatment, insight into the illness, or the ability to set the agenda or control their own experiences. Learners can always collaborate with the patient even in simple encounters:

• What else did you want to talk about at today's visit?
• What/why do you think this is happening?
• What do you think about [X]?
• What questions do you have so far (not just as a wrap-up question)
• Is there anything else I should know about your condition?
• We can stop the physical exam at any time.
• How does that plan sound?

Collaboration is especially vital in lifestyle modification discussions, and open-ended questions are the most effective.

• How could you improve your diet?
• How could you add more vegetables to your diet?
• How could you get more exercise in your day?
• What activities are most interesting to you?

However, a collaborative statement is not a supportive statement. So if the learner says "We'll do this together" or that "I'll be here every step of the way," that's nice and an effective use of reassurance/support, but it's not collaboration. And as I've written before, "Is that OK?" is not a collaborative (or good) question.

Here's an example of how to classify statements that could occur in a smoking cessation case, for example:

• Statement: I tell my patient to start slow, just one cigarette a day.
• Statement: That's something you could do.
• Closed collaboration: Will that work for you?
• Open collaboration: How does that sound?
• Open collaboration: What questions do you have about those recommendations?
• Open concrete collaboration: How many cigarettes do you think you would like to try cutting back on per day?
• Supportive: We'll do this together. We have lots of resources to keep you on track.

Homework:
Keep an ear out for collaborative statements in your next encounter. What could the learner do to invite you into the conversation?

Wit

Happy holidays! Enjoy Emma Thompson in "Wit" while you're on break. "Wit" won the 1999 Pulitzer Prize for drama. It's funny and awkward and moving. Also: poetry! As someone who has done countless consent and DNR scenarios, this is a tough (but interesting! and powerful!) screenplay to watch; I can't imagine what it must be like if you have had cancer or lost someone to cancer.

Bonus gift: "UVM Medical Center hosts production of "Wit". SPs performing in a lecture hall! I wish I worked at an institution where this was possible.

"Wit," which won the 1999 Pulitzer Prize for drama, comes to Burlington thanks to another woman named Vivian — Vivian Jordan, a Shelburne resident who plays the lead role and whose profession merges the performing arts with the medical arts. Jordan works at the hospital as a “standardized patient,” which means she acts out roles for medical students learning how to diagnose illnesses. It brings awareness of end-of-life issues and spark discussion on the complex nature of dying in the Pulitzer Prize-winning play. 

Computer simulations vs SPs

Choose your own adventure!
[La Vérendrye via wikimedia]

I don't know whether to be excited about or skeptical of SIMmersion. A little from Column A, a little from Column B, I guess.

I love technology. I love giving students more chances to practice difficult conversations. As an additional tool in the toolbox, this looks stellar. I can totally see learners using this to practice before an SP encounter.

But then I read things in their press release like:

"A computer screen might not be better for teaching the physical examination of a human, but interacting with a well-designed system is better for teaching students how to talk with a patient [than interacting with SPs]."

If they truly feel this way, and if this is the way they are marketing the product, then the whole foundation is suspect.

I actually went through their sample Motivational Interviewing scenario. Engaging with a computer is fun, and including the MI curriculum as a preview before and as a guide during the encounter is very effective.

But the timing and emotional range is all wrong. Learners, especially beginning ones, struggle with a number of things that can adversely affect patient interactions, like word choices and nonverbal cues. This is especially true in the context of a fast-paced encounter. It's much easier to pick the right statement when you have a limited number of options and as much time as you want to think about it.

Also, there is no verbal feedback in SIMmersions. I strongly believe immediate feedback/debrief with an experienced facilitator featuring student self-reflection is an incredibly effective component of learning. Instead, SIMmersions features a woman in the bottom corner of the screen who responds with appropriate body language based on your response, and offers suggestions for the most effective thing to say next.

I see the usefulness of SIMmersion primarily as an early part of skill acquisition. In my ideal curriculum, learners would develop a new skill like this: beginning with a lecture/introduction, then independent reading/videos, then observation, then SIMmersions, then group work, then SP work with timeouts and a facilitator, then a solo SP.

However, this whole things makes me think we're not far off from The Diamond Age's prediction of "ractors," who are essentially crowd-sourced, on-demand scenario actors able to perform anywhere. Wouldn't that be fun?