I am lying on a hospital bed. I’ve just woken up from the anesthesia and I’m concerned that I can’t move my left arm or leg. The nurse told me that the doctor will be in soon to speak with me. She couldn’t give me any information about why my movement is restricted, and I’m starting to worry. Then the doctor comes in. He’s polite and cordial, and he pulls a chair up to the side of my bed. But he has made no eye contact with me. Now I’m really nervous.
I do work for the Standardized Patient (SP) program at a statewide hospital. The previous paragraph is based on a case I have undertaken often. This type of training is focused on teaching medical students, via comprehensive role play, to incorporate better listening skills and productive interactions within a patient encounter. This program was started in the 1960’s, but really took off twenty years later to address what had become a national problem within the medical profession; doctors, having graduated from data-saturated programs, had little skill in engaging with actual patients. Over time, health research indicated that the absence of skilled patient communication adversely impacted health outcomes across a broad array of hospital systems. The SP program was launched to address this issue.
At its simplest, SP’s take on the role of the patient in a mock medical appointment. They learn the case, symptoms, the patient profile, and engage with the medical student as if they were the actual patient with the symptoms in the case. At the end of the session, the SP will give feedback to the student; they rate the emotional impact of the encounter, the level of perceived patient communication skill, and the physical exam proficiency the student exhibits. Examination elements vary depending on the case, but they begin with a checklist: elements of the exam done correctly, the information that was elicited through adept questioning (that we as SP’s were told to reserve unless directly asked), what information was left out, and most importantly, “Did the student exhibit empathy?” A deft touch with empathy – steering between the rocky shoals of caring and invasion – is required. To do this well demands of the student a healthy dose of humility. Empathy, it turns out, is pretty impossible to communicate if the practitioner is convinced of their own expertise.
Leslie Jamison relays a powerful call for humility in an intriguing chapter about her own experiences as an SP in a book titled The Empathy Exams. “Humility is a kind of compassion in its own right. Humility means (the residents) ask questions, and questions mean they get answers, and answers mean they get points on the checklist.” Points for finding out my mother put me on valium when I was nine years old. Points for getting me to admit my concern that I might have a drinking problem. Points for finding out my father committed suicide when I was seventeen. Points for realizing, as Jamison beautifully puts it “that a root system of loss stretches radial and rhizomatic under the entire territory of a life.”
The situation I had relayed earlier of my own SP experience is one of a category of cases titled “Delivering Bad News”. This case was built, as most are, on an actual situation. A woman had gone into the ER for pneumonia, but due to a medical error, had woken up unable to move the left side of her body. She had had a stroke on the table as a result of a misplaced IV line. The student is to deliver this news to me, the patient, and be present to the emotional reaction, take responsibility, voice regret, offer information, and suggest next steps. Heart, Head and Hands: the listening modalities are all lined up in those requirements.
The medical profession, by necessity, is full of problem solvers with deep data retention skills. There is a heavy saturation of Head and Hands listeners. But unless there is also Heart listening, it’s difficult for the physician to gain the patient’s trust. Part of the mission of the SP program is to empower the patient to see the physician as a partner in their healthcare, not simply as the “expert” that will “fix” the problem. But too much Heart listening can result in loss of authority for the practitioner, as well as mistrust on the part of the patient.
I have to mention that the students I worked with for this session were in their first year of the program. Even so, the wide range of interpersonal skill at work was startling. While many struck a good balance between empathy, responsibility and authority, others seemed overwhelmed, exhibited huge remorse, and even burst into tears at having to deliver the awful news. The scenario sometimes would come to a halt as no relevant information was given, and little problem solving emerged.
On the opposite end, I saw those (few) who hid behind the corporate “we” – as in “We made a mistake and we’re sorry”. They couldn’t bring themselves to take responsibility; they couldn’t even look me in the eye. I noticed in myself that, along with my fear, I felt a growing anger in response to this emotional disconnect. These encounters helped me understand viscerally why so much punishing litigation aims directly at doctors and hospital systems.
Within a year or two of being in this program, I learned to pay attention to not only how well the student employs reflective listening, and conveys empathy, but also, what the student may have been actively listening for in these encounters, and the role this played in their subsequent diagnostic interpretations.
This is a segment from my book: “Head, Heart & Hands Listening in Coach Practice” on sale now at a special price through Routledge Publishing