Against Standardized Patients for the Training of Medical Empathy
I was getting tea with my long-unseen friend the other day—in the often tiring manner in which we entertain the prospect of “catching up;” as it turns out trying to recapitulate an entire year of life in a single hour is not only impossible, but exhausting to attempt—when the conversation turned to my friend’s patients, as she happens to be a clinical psychology graduate student. This isn’t anything new for me: as a medical student, I’m often subjected to my classmates and professors speaking at length about their patients, more often than not divulging information that is most likely private, and while probably not a direct in violation of HIPAA, tends to, in my opinion, betray the implicit privacy that us as physicians promise to our patients in exchange for their stories.
Before we forayed into the private realm of her patients, however, we had been talking about our daily stressors and anxieties, and coincidentally, as we had discovered, both of our recent attempts to practice mindfulness meditation in search of an antidote. When we turned to her clinical practice however, I asked if she practices counted breathing or any other mindfulness exercises with her patients suffering from anxiety or depression. What she said in response bothered me even more so than the patients’ stories she divulged to me—she did practice mindfulness with her patients, mostly with guided meditation videos from YouTube, for five to ten minutes at the start of each session, but added that she never joined them during—not that she didn’t want to, but rather because she felt a sort of barrier in doing so, as if it were impossible to relinquish her status as the “clinician” in front of the “patient,” and return to a simpler, (and frankly more obvious) mode of being, that of two humans having a conversation.
Neither was this a hasty interpretation I had made about her practice, as she continued on to explain that she had two separate “faces:” one was her “real face,” the one that she wore in her everyday life, and the other being a “therapeutic face” that she put on during her interactions with patients in the office. This was alarming, and it had plucked out a thread that had been running through my mind, annoyingly so, for the past few months that I had been hard-pressed to locate. The multi-faced-ness of the doctors and medical students I was spending all my time with in the hospital, and an accompanying, insidious, pulling-away from my natural communication style towards a “therapeutic face” which I did not recognize.
This phenomenon, as frighteningly or silently it may have crept up on me over the past two years of my medical training, is not surprising in or of itself. There is no doubt that most or all people—clinicians or otherwise—have different manners in which they interact with different people in their lives. After all, we don’t expect to speak to the gas station attendant the same way we speak to our grandmothers. Exceedingly rare and praiseworthy is the person who speaks with the same intention and transparency to all he meets. What is frightening, however, is the sheer disingenuousness of that “therapeutic face” that I recognized in myself and in others, how pervasive it seems to be within the medical-school pedagogy, and how ready medical students (and I presume healthcare-students of all types) are to accept it as the default mode of interaction with patients.
I believe this to be the fault of a clinical education that pins the training of “medical empathy” in large part (at least at the fledgling, premature stages of ones’ clinical education) on actors, in the form of “Standardized Patients.” For the unfamiliar, standardized patients, or “SP’s,” are actors paid by medical schools to act as patients for the training of clinical encounters. Students during these encounters are graded firstly, on their ability to diagnose the SP with a medical condition, based on the set of symptoms and complaints the SP memorizes from his or her script, and secondly, on the student’s communication style—in effect, what the SP grades us on, via a quite rigid rubric (based on what we did or did not ask), is our ability to elicit the SP’s needs and concerns in a safe and “empathetic” manner.
Henry David Thoreau, in A Week on the Concord and Merrimack Rivers, as part of a larger memorandum on friendship, guides us in the pitfalls of communication based entirely in language:
“It is an intelligence above language. One imagines endless conversations with his Friend, in which the tongue shall be loosed, and thoughts be spoken without hesitancy, or end; but the experience is commonly far otherwise. Acquaintances may come and go, and have a word ready for every occasion; but what puny word shall he utter whose very breath is thought and meaning? Suppose you go to bid farewell to your Friend who is setting out on a journey; what other outward sign do you know of than to shake his hand? Have you any palaver ready for him then; any box of salve to commit to his pocket; any particular message to send by him; any statement which you had forgotten to make—as if you could forget anything? No; it is much that you take his hand and say Farewell; […] Have you any last words? Alas, it is only the word of words, which you have so long sought and found not; you have not a first word yet.”
Here Thoreau warns us of the experience that commonly masquerades as friendship, in other words, the conversation that has a “word ready for every occasion,” yet has nothing to say. In our daily lives, this is the type of shallow, “superficial” speak of which we all dread, yet find ourselves often held hostage to, yet in the realm of the standardized patient encounter, and subsequently in the hospital with patients, this conversation would receive a full score, or in the case of the hospital, avoid any overlooked information, nevertheless completely ignorant of the fact the words and sentences being spoken in it are void totally of any real meaning.
There is a confusion of these two types of conversation inside the hospital, however (and outside, although I will try and limit myself to the former for the time being), exactly in the manner my friend described. There seems to be a dominant belief that empathy consists of speaking the “right words,” as it were, (puny words, perhaps) in order to elicit the proper response. The metaphor of “stepping into another’s shoes,” as empathy is commonly described, and as it attempts to be practiced in the standardized patient encounter and in the hospital, only extends as far as we can speak it into being. Just as Thoreau attempts to find the last words to speak to his departing friend, doctors find themselves caught in the same conundrum, only they have not found the hand to shake, nor the breath of thought and meaning, but are still searching for boxes of salve to commit to their patients’ pockets.
This was the case of an attending I worked with the other week; a quiet young man who had recently been granted his full licensure. We were rounding on an old woman who had a terrible night in the hospital (I will omit the details here, but rest assured, I would not wish the terrible course of events that happened to this woman on anyone), and when we walked into the room, she was sitting upright, and before we could check up on her, immediately began to detail her night, particularly how the two of us were at fault for every wrongdoing and unfortunate event that occurred overnight. Whether or not this was the case is besides the point. The attending seemed frozen in fear, turned beet red, and squatted down to meet her at eye level (full marks from an SP here). He gave her ample time for her to yell at us, (whether or not this was intentional or simply because he was searching his brain for the proper response, I don’t know, but again, would have received full marks here from an SP), and intermittently managing an “I’m sorry,” when he found space.
And still, everything he was saying was so clearly from behind his “therapeutic face” that is was almost impossible to take him seriously, either as the patient or as an observer. The stale, repeated apologies simply hung in the air, as if the longer they stayed around, the more likely they were to be heard, checked off, and therefore found meaningful. There was no attempt at an explanation for the events that had transpired, or learn from the patient what she would like to do or see now, all directions that would presumably be taken in a real conversation with a friend. Instead, there were only his empty, stuttering apologies, and long periods of silence in between. He was star-struck with what seemed like a mix of guilt, fear, and shame, all the while frozen with the searching gaze and tone of voice of someone who is racking his or her brain for the “right answer,” as if the proper word would unlock some secret ending in the script of the standardized patient (in his case, the attending must have thought that the phrase “I’ll have a discussion with the resident,” was indeed this silver bullet, only through some mistake in the standardized encounter was the SP not properly registering the phrase, and through sheer repetition he could “get it to work.”)
Unfortunately for all of us in the room, it was not the right answer, and the interaction continued on, and this poor lady (or poor attending, I honestly couldn’t tell who was in greater distress at this point) received no explanation or recompense for her terrible night. Having failed to use his therapeutic face, the young attending, still practically half-mute, found no other way to “continue the encounter,” and as one would leave the room of a standardized encounter after the prescribed twenty minute mark is hit, muttered one last apology, turned around silently, and left with me trailing close behind.
The standardized patient interview is formatted as a test of investigation and algorithm, and nothing more. It is not that which it purports to be—neither empathy nor communication skills are adequately assessed with these tests. It is simply an organized dance, with the medical student asking questions in an attempt to elicit pre-written answers that have been memorized by the SP. In a conversation that one would have with his or her “real face”, one with an “intelligence above language,” one asks questions in an effort to create answers, to spur new thoughts and feelings. The answer is not always at the ready, and often times it is uncomfortable. However, it is not uncomfortable for the reasons that my attending found it to be, that is, being unable to find the “correct” response, but rather, because one must discover something new or genuine about him or herself in an effort to move forward. In the standardized interview, however, each and every response has been planned, pre-written, and memorized in advance of the question. Any hesitancy or seeming contemplation is built into the script, just as a character in a play would (pause contemplatively) before delivering their lines. There is no investigation, realized change, or honest inquiry on either part. Often the purpose of the standardized interview (sometimes explicitly stated, other times not) is to test “empathy.” What this requires, however, are the aforementioned qualities of both question and answer—one cannot genuinely exist without the other.
If the argument is made that standardized patients are simply for the “testing,” or “sandboxing,” of communication skills, and the “honing” of “real” empathy must take place in the hospital with real patients, then I would point one to the doctors and medical students in the hospital—one will find no more “real” inquiry there than in the standardized encounter; it is the same pointed questions, the same awkward “box-checking” that fills the rooms where sharpened, endlessly-honed “therapeutic faces” meet real, deeply suffering people.
It has been countless moments like these that have made me wonder why we still expect SP’s to train us with an adequate sense of how to speak to people, or why we expect our conversations with patients to be scripted while our conversations with everyone else not to be. Firstly, I wonder if medical schools self-select for this type of ineptitude at basic conversation. If not, could it the case that medical schools are taking already well-spoken people and encumbering them with this difficulty through the use of standardized patients?
If it is the first of the two, the there may be no solution other than to broaden medical school admission to a wider audience, and select for communication (if we as a society, or medicine as an institution, even value conversation and real, human-like speech as necessary traits anymore) over a machine-like memory. If it is, however, the second of the two, then there is much to be salvaged: standardized patients do indeed train budding clinicians to hone their diagnosing skills, physical exams, but to pretend that standardized patients can be used to entrain empathy, dialogue, or really anything other than introductory “doctoring skills” is a mistake. Nevertheless, it is a mistake that provides a real opportunity to improve medical school pedagogy for the better. We may not have found the perfect words to describe empathy, nor the perfect method—if there is one—to teach it, but “alas, it is only the word of words, which you have so long sought and found not; you have not a first word yet.”