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My SP Disease

“Did you notice what you were doing there with your hands? You were going like this,” he said, wringing his hands into knots. “I could see how uncomfortable you were and that made me uncomfortable. Does that make sense?”

“Of course,” I said, “I would expect it to.”

His hair was spiky, silver, and short, buzzed at the sides. Black glasses framed his thin face, and he wore a short-sleeve button-down, and maybe jeans — I don’t remember. Behind his glasses were wide blue eyes.  Occasionally, he would break to the side, bring a closed fist to his mouth, and cough.  I especially remember the quick, tight nods with which he replied to my summary of his symptoms. His eyes darted with the same quickness.

The darting eyes, the urgent speech, the way he sat forward on edge, the persistent cough, the rigid posture, all these separately hinted at some underlying agitation. Taken together, with his answers to my questions, they pointed to a disease. With my first question I extracted his chief complaint. Over the last two days, walking quickly and lifting weights were enough to make his breathing rapid and shallow and to cause an uncomfortable tightness to form in the heart of his chest. I must give him credit for his appearance because he was, in fact, an actor, a standardized patient (SP), hired to help me hone my social doctoring skills. He truly looked anxious and uneasy, not at all well, and I found his harsh cough compelling.

I was surprised when he pointed out that I had been wringing my hands. It’s not something I do often. I thought instead that he would comment on a lack of compassion or on my habit of responding to each of his answers with a solemn “okay.”  I must have been trying to choke the nerves out of my hands, the way I was moving them against each other. More importantly, however, I soon realized that I felt much less empathy and compassion while listening to him than I usually did when hearing patient stories. Actually, I was certain I had felt none at all. I blamed the nerves and the need to focus on a script. Preoccupied with saying the right words and extracting and retaining the relevant information, all while appearing calm, concerned, and confident, I left little room to imagine or contemplate what the SP might be feeling.

During my second SP interview, I decided to do better and show compassion with words as well as demeanor.  Even though I could not get out of my head that she was an actor, I made sure to stick an “I’m sorry to hear that” right into the middle of our conversation. The young woman, smiling despite her upset stomach, thanked me with a dip and a turn of her head.  I covered the rest of my bases as far as the history of present illness was concerned and found myself with a couple minutes to go, so I thought I might try to tease out a diagnosis.  Thanks to our Microbiology course, I felt compelled to ask about recent travels.

“About a month ago I was in St. Louis for a few days but that’s about it,” she said.

“What were you doing in St. Louis?”

“Visiting friends.”

“Did you have a good time?” I asked smiling.

“Yes, I did!” she said, smiling back.

Her smile convinced me she enjoyed the respite from the rote and scripted questions I was required to ask. This time my hands had remained still throughout. Nevertheless, she told me that I hadn’t smiled enough. I left her doubting as to whether I was actually a nice guy. And there I had been, making a conscious effort not to over-smile, thinking it would be inappropriately making light of her discomfort.

On the other side of the room I could hear an SP telling my classmate that she should smile less.

Still, I did not empathize with the second SP either. Initially, in the days that followed, I believed it was my preoccupation with the whole get-up that precluded any “real empathy.” After all, these “patients” are acting, you are acting, your classmates and preceptors are watching, and there is a checklist to run through. With the first SP it was all too much. What I tried to tuck away and hide beneath a focused gaze and a portrait of concern trickled out into my wrists and fingers and trumpeted to the room my own dis-ease. However, during my second SP interaction, I was confident and relaxed, less in my head. I felt more engaged and conversational. I thought then that I might get used to the artificiality of the SP experience, and that the empathy would follow.

I assumed this meant that as the semester progressed, I would find it easier to empathize with SPs. But it also followed that I would have to be aware of the potential for my own discomfort or anxiety to get in the way of my tendency to naturally empathize, even on the wards.

August became September, then October, and I had many more opportunities to interact with SPs, and finally a few mornings in the hospital with patients as well. These patients were children, and it was impossible not to feel for them the moment I walked into the room. I was pleased to find that compassion and empathy were my dominant feelings on the hospital wards.

At one point, I found myself in a room with the doctor I was shadowing, a dying two-year old girl, and her mother. The girl, barely able to move more than her eyes, lay immobile upon her hospital bed, spent, and taking breaths that filled her entire body, which showed she was still alive. She wasn’t crying, or making any noise. Just breathing. There was no physical sign of illness either, no external symbol of her pain other than her eyes and her unceasing, full-body breaths. I remember being struck by what felt like a mature consciousness in her. I think it was a trick of her pain. I wasn’t used to seeing so much suffering in eyes that belonged to so young and so little a body.

Contrary to my initial expectations, I have not found it any easier to empathize with SPs. I know too well that the interaction is artificial. Following my recent experiences on the wards, I know that my difficulty empathizing with SPs bears no implication for my ability to empathize with patients. The artificial nature of the SP interaction magnified my own discomfort and unease, which the encounter with real suffering muted. I am now entering a part of my medical education where interacting with patients and not SPs will be the norm. That, to me, is thrilling.

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